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View CMS (HCFA) Forms
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Important
Notice: The
CMS-1500 Form is being revised. The Department of Health &
Human Services (DHHS)and the Centers for Medicate & Medicaid
(CMS) are revising the CMS-1500 form to acoomodate the reporting
of the National Provider Indentifier (NPI). The revised version
will be Form CMS-1500 (08/05) Click
to see example of proposed new form. Either the old OR the
new version may be used until April 1, 2007. After
April 1, 2007, ONLY THE NEW FORM IS TO BE USED. For
a full description of these changes, see http://www.cms.hhs.gov/transmittals/downloads/R899CP.pdf.
Until the new form is officially released, we will continue
to ship the current version CMS-1500 (12/90).
NOTE:
The new CMS-1500 Form does not have a bar code.
Below
are listed the NEW forms only. If you still need to order the
old version, please call or mail your order in.
|
| Online ordering of CMS Forms is temporarily
unavailable. Please Phone (800)716-4600,
Fax (800)662-4651, or Mail
your order. |
For
a preview click on the form number.
|
| FormNumber |
Description |
Quantity
Per Case |
Parts |
|
CMSLC
|
CMS-1500
Laser Cut Sheet (08/05)
|
2500
|
1
|
|
CMS1
|
CMS-1500
1 part continuous (08/05)
|
2500
|
1
|
|
CMS2
|
CMS-1500
2 part continuous (08/05) (White/Canary)
|
1000
|
2
|
|
CMSW2
|
CMS-1500
2 part continuous (08/05) (White/White)
|
1000
|
2
|
|
CMS3
|
CMS-1500
3 part continuous (08/05) (White/Canary/Pink)
|
1000
|
3
|
|
CMSS
|
CMS-1500
2 part Snap-out-sets (08/05) (White/Canary)
|
1000
|
2
|
|
CMS1B
|
CMS-1500
1 part continuous w/label (08/05)
|
2500
|
1
|
|
CMS2B
|
CMS-1500
2 part continuous w/label (08/05)
|
1000
|
2
|
|
|
|
|
4-Pt. Home Health Certification |
500 |
4
|
|
|
3-Pt. Home Health Update |
1,000 |
3
|
|
|
4-Pt. Home Health Addendum |
500 |
4
|
|
|
Laser Dental (1987 Version) |
2,500 |
Laser
|
|
|
1-Pt. Dental (1987 Version) |
2,500 |
1
|
|
|
2-Pt Oxygen |
1,000 |
2
|
|
|
2-Pt Section C Continuation Form |
1,000 |
2
|
|
|
UB-92 Self-Seal Jumbo Envelope |
500 |
Env
|
|
|
2-Pt. Dental (1987 Version) |
1,000 |
2
|
|
|
Laser Dental (1990 Version) |
2,500 |
Laser
|
|
|
1-Pt. Dental (1990 Version) |
2,500 |
1
|
|
|
2-Pt. Dental (1990 Version) |
1,000 |
2
|
|
|
Laser Dental (1994 Version) |
2,500 |
Laser
|
|
|
1-Pt. Dental (1994 Version) |
2,500 |
1
|
|
|
2-Pt. Dental (1994 Version) |
1,000 |
2
|
|
|
Laser UB-92 Hospital Claim Form |
2,500 |
Laser
|
|
|
1-Pt. UB-92 Hospital Claim Form |
2,500 |
1
|
|
|
2-Pt. UB-92 Hospital Claim Form |
1,000 |
2
|
|
|
3-Pt. UB-92 Hospital Claim Form |
1,000 |
3
|
|
|
4-Pt. UB-92 Hospital Claim Form |
500 |
4
|
|
|
5-Pt. UB-92 Hospital Claim Form |
500 |
5
|
|
|
2-Pt Hospital Bed |
1,000 |
2
|
|
|
|
|
2-Pt Support Surfaces |
1,000 |
2
|
|
|
2-Pt Motorized Wheelchairs |
1,000 |
2
|
|
|
2-Pt Manual Wheelchairs |
1,000 |
2
|
|
|
2-Pt Continuous Positive Airway |
1,000 |
2
|
|
|
2-Pt Lymphedema Pumps |
1,000 |
2
|
|
|
2-Pt Osteogenesis Stimulators |
1,000 |
2
|
|
|
2-Pt Transcutaneous Electrical |
1,000 |
2
|
|
|
2-Pt Seat Lift Mechanisms |
1,000 |
2
|
|
|
Attending Dentist's Statement (2000) 2-Pt.
Cont. |
1,000 |
2
|
|
|
2-Pt Infusion Pumps |
1,000 |
2
|
|
|
2-Pt Parental Nutrition |
1,000 |
2
|
|
|
2-Pt Enternal Nutrition |
1,000 |
2
|
|
|
Number 10 1/2 Single Window |
500 |
Env
|
|
|
Number 10 1/2 Single Window Self Seal |
500 |
Env
|
|
|
Jumbo Right Window Envelope 9" x 12 1/2" |
500 |
Env
|
|
|
Jumbo Right Window Envelope No Wording
9" x 12 1/2" |
500 |
Env
|
|
|
Jumbo Left Window 9 |
500 |
Env
|
|
|
HCFA-1500 1-Pt. With Bar Code (12-90) |
2,500 |
1
|
|
|
HCFA-1500 2-Pt. With Bar Code (12-90) |
1,000 |
2
|
|
|
HCFA-1500 Laser With Bar Code (12-90) |
2,500 |
Laser
|
|
|
HCFA-1500 2-Pt. With Bar Code (12-90)
Snap-a-part |
1,000 |
2
|
|
|
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