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60162 CMS 1 Part Laser Claim Form 02/12 Imprinted 8 1/2 x 11"

Manufacturer: NEBS
Manufacturer Part No: 60162-1
60162 CMS 1 Part Laser Claim Form 02/12 Imprinted
Size: 8 1/2 x 11"

Includes all updates to the 02/12 version approved by the NUCC (National Uniform Claim Committee)

  • Personalized forms add professionalism, help avoid processing errors.
  • Free personalization includes: imprinted name, address, phone number, and NPI number.
  • Convenient to use, 1-part form on 20# white bond stock.
  • Printed in OCR red ink.
  • Accepted by most health insurance companies.
  • Single sheet format works with most laser printers.
  • Choose a typestyle for your company name.
  • Imprint area: 2 1/2 x 3/8"
  • 100% Satisfaction Guarantee.
  • Higher quantities are available at discounted prices.
  • Speak to a customer service specialist at 855-5FORMS5 or 855-536-7675. 9AM - 7PM EST Monday - Thursday and 9AM - 5PM EST on Friday.

NOTE: You may put any information you want in the Company Imprint lines to the right. The text shown above each entry field is for suggestion purposes only. Your company information will be printed exactly as you type it. Be sure to double-check your work.

Important: Enter your printable text exactly as you would like it to appear, using only the lines that you need. Please check for accuracy. Please be sure to double-check your spelling, punctuation, abbreviations and all other content.

Your Price:
Starting at $86.63

Pricing Options

Quantity & Pricing:

Personalization

* denotes required field

Choose a Typestyle.*
Enter Typestyle IDClick Here For Typestyles typestyles1-6-8-16.htm
Enter Phone Number
Enter Billing Provider Info
Business Name or Main Line of Text
P.O. Box or Street Address
City, State, Zip
Enter Service Facility Location Info
Business Name or Main Line of Text
P.O. Box or Street Address
City, State, Zip
Enter Federal Tax I.D. Number
Enter Box 32a
Enter Box 32b
Enter Box 33a
Enter Box 33b
Enter SSN Check Box
Enter EIN Check Box
We can send a proof by email in 24-72 Hours*
Optional:
Include any comments you feel we need to know when processing this order.
free shipping

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$86.63 60162 CMS 1 Part Laser Claim Form 02/12 Imprinted 8 1/2 x 11"

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