CMS 1500 Claim Forms - Chiropractor Claim Forms

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$11.09 - $106.89
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 New 1500 CMS Claim Forms

Where to Put Your Focus
Every Physician Makes a Good Referral

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"

Available Formats

  • 1 Part Continuous (for pin style printers)
  • 2 Part (carbon copy) Continuous (for pin style printer
  • Laser (for standard laser printers)

More Information
Manufacturer Number 790-0116QR, 790-0120QR, 790-0129QR, 790-0116PK, 790-0129PK
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Questions Arrow Questions: What is the difference between the 1 Part and 2 Part forms? Also, what is the abbreviation Cont." mean?" 0 Answers
Questions Arrow Questions: What is the difference between part 1 and part 2 form? 0 Answers