CMS 1500 Claim Forms

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Cmfi Group CMS 1500 Claim Forms

New 1500 CMS Claim Forms


As of April 1, 2014, Medicare will only process paper claims submitted on the revised CMS 1500 claim form
Allows healthcare providers to bill a patient's insurance company for reimbursement
  • Approved by the National Uniform Claim Committee (NUCC); HIPAA compliant
  • This form was revised to align the paper form with some of the changes in the electronic health care claims: Professional (837), 005010X222 Technical Report Type 3 (5010) and 005010X222A1 Technical Report Type 3 (5010A1)
  • The most significant change was the addition of 8 diagnosis codes in field 21
  • Includes new QR code identifier at the top of the form that supports and aligns with Industry scanning systems
  • Printed with OCR "dropout" red ink on 20lb. paper (per government regulations)
  • Form not available personalized
  • Certified Chain of Custody; promotes sustainable forest management
  • Size: 8-1/2x11"


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Place Your Order Here

Cmfi Group CMS 1500 Claim Forms

790-0129PK - Cms 1500 Claim Form- Laser, 50/Pack - $9.49

790-0116PK - Cms 1500 Claim Form 1 Part Cont. 50 Packs - $9.49

790-0120PK - Cms 1500 Claim Form- 2 Part Continuous, 20/Pack - $22.31

790-0116QR - Cms 1500 Claim Form- 1 Part Cont. 2500 Sheets/Case - $54.99

790-0129QR - Cms 1500 Claim Form- Laser 2500 Sheets/Case - $67.99

790-0120QR - Cms 1500 Claim Form- 2 Part Cont. 1000 Sheets/Case - $86.89


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CMS 1500 Claim Forms
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Part Number(s): 796 0018, 796 0019, 796 0020, 796 0024, 796 0023, 796 0022

Mfg Part Number(s): 790-0129PK, 790-0116PK, 790-0120PK, 790-0116QR, 790-0129QR, 790-0120QR

Scrip Part Number(s): 796 0024, 796 0022, 796 0023, 796 0018, 796 0020, 796 0019

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