Page 7 of replacement superbill forms
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Custom Carbonless CMS Forms, 8-1/2" x 11", 100 Sheets per Pad
Item #: 901-QFW1471901
For use by all medical facilities for billing insurance companies, Medicaid and Medicare; aligned with the electronic HIPAA ASC X12N 837 Non-institutional Transaction Standard
8-1/2" W x 11" L
1-part, white, carbonless; carbon paper is required for duplicates
Medical Arts Press® Registration Form Featuring Updates Section/Blue Wave
Item #: 901-33018
HIPAA compliant insurance authorization
Help ensure reimbursement and improve risk management
Collects printed name and relationship to patient
$24.59
Per pack
Custom Florist Register Form, Colors Design, Large Format, 2 Parts, 1 Color Printing, 5 1/2" x 8 1/2", 500/Pack
Item #: 901-D672T2B
Get the details: Shows so much more than a cash register receipt
Keep accurate records: Choice of different layouts for tax and delivery options
Work smarter: Compatible with our registers (sold separately)
Custom Carbonless 3-Part Forms, 5-1/2" x 8-1/2", 250 Sets per Pack
Item #: 901-QFNM3P1S1R
Design your own forms using your own artwork
5-1/2" W x 8-1/2" L
3-part, white/canary/pink, carbonless
Custom Registration Forms, 8-1/2" x 11", 250 Sheets per Pack
Item #: 901-QFN105XX1R
For use in patient charts
8-1/2" W x 11" L
White 20# text stock with preprinted template; custom imprint printed in black ink
Custom Repair Order Forms - Jewelry Repair Orders with Poly Bag, 3 Parts, 1 Color Printing, 4 3/16" x 7 5/8", 200/Pack
Item #: 901-D3223
Third part has adhesive on back for attaching poly bag - helping you stay organized
Resealable, heavy-duty clear plastic bags (5 x 8") attach to forms and keep jewelry and repair order together
Consecutive numbering: These forms come with the option to have consecutive numbering printed on them
Custom Florist Register Form, Colors Design, Large Format, 3 Parts, 1 Color Printing, 5 1/2" x 8 1/2", 500/Pack
Item #: 901-D672T3B
Get the details: Shows so much more than a cash register receipt
Keep accurate records: Choice of different layouts for tax and delivery options
Work smarter: Compatible with our registers (sold separately)
NAHANCO Ladies' Half Round Display Form, White
Item #: 901-216447NAH
Dimensions: 30 x 15 x 10 x 7"(Deep)
Style: Torso
Metal hanger hook included
$55.99
Per each
Custom Carbonless Anesthesia Consent Form, 3-1/4" x 5", 100 Sheets per Pad
Item #: 901-QFW1056501
Self-duplicating; everything is printed on original and duplicate
3-1/4" W x 5" L
White self-duplicating carbonless stock; pre-printed in black ink
Custom Jewelry Register Form, Classic Design, Small Format, 3 Parts, 1 Color Printing, 4" x 6", 500/Pack
Item #: 901-D6072
Just for jewelers: Room for special instructions, like engraving, sizing & more - on one convenient form
Layaway agreement & payment record printed on back
Compatible with our registers
Custom Multi-Purpose Register Form, Classic Design, Large Format, 3 Parts, 1 Color Printing, 5 1/2" x 8 1/2", 500/Pack
Item #: 901-D6103
Use with your portable register to capture details on the spot - no hunting for a handy place to write
Preprinted areas simplify write-ups of customer information, salesperson, description of items, payment method & more
Compatible with 5 1/2 x 8 1/2" portable registers, sold separately
Custom Dental After-Treatment Instruction Forms, 8-1/2" x 11", 100 Sheets per Pad
Item #: 901-QFN105611R
Use for patient care instructions
8-1/2" W x 11" L
White 20# text stock; printed in black ink
Custom Carbonless 2-Part Dental Diagnosis and Estimate Forms, 8-1/2" x 11", 250 Sheets per Pack
Item #: 901-QFN102621R
For use in providing estimates and treatment plans
8-1/2" W x 11" L
2-part, white/canary, carbonless; printed in black ink
Custom 1-Sided Insurance Registration Forms, 8-1/2" x 11", 250 Sheets per Pack
Item #: 901-QFN105011R
For use in patient charts
8-1/2" W x 11" L
White 20# text stock; printed in black ink
Custom Carbonless Veterinarian Surgical Consent Form, 5-1/2" x 8-1/2", 100 Sets per Pad
Item #: 901-QFW1302901
Self-duplicating; everything is printed on original and duplicate
5-1/2" W x 8-1/2" L
White self-duplicating carbonless stock; pre-printed in black ink
Custom 3-Part Service Form Books, 4" x 5-1/2", 50 Sets per Book
Item #: 901-QFW1603301
Contains space for material and labor costs
Books are 4" W x 6" L; detached forms are 4" W x 5-1/2" L
3-part, white/canary/pink, carbonless, pre-printed in black ink
Custom Full Color 2-Part Carbonless Forms, 5-1/2" x 8-1/2", 250 Sets per Pack
Item #: 901-QFN21NAVQ
Design your own forms using your own artwork
5-1/2" W x 8-1/2" L
2-part, white/canary, carbonless
ComplyRight 2024 2-Part Time Off Request and Approval Form, Pack of 50 (A0045)
Item #: 901-24202398
Calendar format makes it easy for employees to select and submit time off requests
Ensures a consistent request and approval process for all employees
Attorney-approved to ensure 100% compliance
$73.99
Per each
ComplyRight 2023 2-Part Time Off Request and Approval Form, Pack of 50 (A0030)
Item #: 901-24202397
Calendar format makes it easy for employees to select and submit time off requests
Ensures a consistent request and approval process for all employees
Attorney-approved to ensure 100% compliance
$116.99
Per each
Custom Carbonless 3-Part Forms, 4-1/2" x 5-1/2", 1000 Sets per Pack
Item #: 901-QFN132151R
Design your own forms using your own artwork
4-1/2" W x 5-1/2" L
3-part, white/canary/pink, carbonless
Custom Service Order Register Form, Classic Design, Large Format, 2 Parts, 1 Color Printing, 5 1/2" x 8 1/2", 500/Pack
Item #: 901-D6312
Compatible with our register holders
Preprinted section. Includes preprinted section, for customer to sign-off on service/work as acceptable
Consecutive numbering: These forms come with the option to have consecutive numbering printed on them
Custom Work Order Register Form, Classic Design, Large Format, 2 Parts, 1 Color Printing, 5 1/2" x 8 1/2", 500/Pack
Item #: 901-D6212
Preprinted section: Includes preprinted section, for customer to sign-off on service/work as acceptable
Compatible with our registers
Consecutive numbering: These forms come with the option to have consecutive numbering printed on them
Custom Carbonless 2-Part Forms, 5-1/2" x 8-1/2", 2 Standard Inks, 250 Sets per Pack
Item #: 901-QFNM2P1S2R
Design your own forms using your own artwork
5-1/2" W x 8-1/2" L
2-part, white/canary, carbonless
Custom Florist Register Form, Classic Design, Large Format, 2 Parts, 1 Color Printing, 5 1/2" x 8 1/2", 500/Pack
Item #: 901-D6722D
Multiple layout options: Choice of different layouts for tax and delivery options - Layout A: Del, Tax, Layout B: Tax, Del, Layout C: Blank, Layout D: Tax
Compatible with our registers
Additional customization options include imprinting your custom logo