MEDICAL OFFICE FORMS & PRODUCTS

CMS-1500 FORMS
(New Revision)

UB04 FORMS
(Replaces UB92)

HIPAA COMPLIANCE FORMS

HIPAA Information

HIPAA Compliant Confidential Patient Sign-In System

HIPAA Compliant Confidential Patient Sign-In Sheets with adhesive strips

(HIP02) Blue
(HIP02GN) Green
(HIP02BY) Burgundy
(HIP04) Bi-Lingual, English/Spanish

Confidential Sign-In Logs (Generic)

HIPAA Employee Training Record
(Form #101)


HIPAA Practice Training Record
(Form #102)


Protected Health Information (PHI) Access Log
(Form #103)


Protected Health Information (PHI) Disclosure Log
(Form #104)


Patient Request for Amendment of Health Information
(Form #105)


Patient Requests for Accounting of Disclosures
(Form # 106)


Patient Request to Inspect/Review PHI
(Form #107)


Patient Request for Confidential Communications
(Form #108)


Patient Request for Restrictions on Use & Disclosure of PHI
(Form #109)


PHI Tracking Log
(Form #110)


Authorization to Release Information
(Form #111)


Notice of Privacy Practices
(Form #120)


Notice of Privacy Practices
Spanish Version
(Form #120S)



ENVELOPES

Claim Form Envelopes
for CMS/HCFA-1500 & UB04 claim forms


Dental X-Ray Envelopes

Patient Valuables Envelopes


PHYSICIAN'S ORDER SHEETS

Physician's Order Sheets
DPO3

Physician's Order Sheets
DPO4

Physician's Order Sheets
DPO5



NARCOTIC CONTROL RECORDS

Drug Administration Records
with Pharmacy Receipts
(DNC10)

Drug Administration Records
with Pharmacy Receipts
(DNC25)


Controlled Drug Administration Records
(D150-10)

Controlled Drug Administration Records
(D150-25)

Controlled Drug Administration Records
(D250-10)

Controlled Drug Administration Records
(D250-25)



LABORATORY MOUNT SHEETS

Physician's Telephone Orders
(DTO4)

Physician's Telephone Messages
(DTM4)

Laboratory Reports
(DC5)

Laboratory Reports
(DD5)

Laboratory Reports
(DVT3)

Laboratory Reports
(DVT5)

Laboratory Reports
(DVT13)

Laboratory Reports
(DVT5)

Laboratory Reports
(DH3)

Laboratory Reports
(DH5)


 

AMERICAN HCFA FORMS

YOUR BEST AND FASTEST SOURCE FOR CMS, UB04, HCFA HEALTH INSURANCE CLAIM FORMS
~ Claim Forms Starting at $19.99 ~

CMS 1500 FORMS (Newest Revision - 02/12 Version)   CMS 1500 FORMS (08/05 Version)

UB04 FORMS (Replaces UB92)HOME HEALTH FORMS,   CMS (HCFA), UB-04 Envelopes

We have the Old  HCFA 1500 Forms - 12/90 Version (Click Here) and UB 92 Forms (Click Here)

TO ORDER CALL US TOLL FREE ( 8-5 Mon-Thurs.,  8-12 Friday CST ) or ORDER SECURE ON-LINE

CMS Forms

NATIONWIDE DELIVERY
1-877-840-1500

We have UB04 Forms!
CLICK HERE

ALL OUR FORMS ARE OF THE HIGHEST QUALITY, ARE PRINTED IN STRICT COMPLIANCE WITH GOVERNMENT SPECIFICATIONS AND ARE APPROVED BY CENTERS FOR MEDICARE AND MEDICAID SERVICES AND THE INSURANCE INDUSTRY.
OUR FORMS HAVE BEEN APPROVED BY THE GOVERNMENT
The American HCFA Forms division of DFL Enterprises, Inc. is an independent supplier of US Government approved claim forms and NOT an affiliate of CMS (www.cms.gov)

 

 CMS 1500  CLAIM FORMS  (Newest Revision - 02/12 Version) - SEE TIMELINE BELOW

WILL NOT BE ACCEPTED FOR CLAIMS SUBMISSION
UNTIL JANUARY 2014
SEE TIMELINE BELOW for implementation of this form
Current Version CMS 1500 Claim Forms (Version 08/05) are Still Available!
CLICK HERE for Current Version (Version 08/05)

Individual Sheets

Continuous

CLICK IMAGE TO ENLARGE

TO ORDER
CONTACT US TOLL FREE AT:
1-877-840-1500
8-5 Mon-Fri CST
OR
ORDER SECURE ON-LINE

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OF PAGE

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Description
CMS 1500
 CLAIM FORMS
(Newest Revision)

Quantity/
Case

Price/
Case

CLICK HERE TO

Individual
Sheets

500

$19.99

Individual
Sheets

2500

$35.00

1 Part Continuous

2500

$35.00

2 Part Continuous
1st Sheet White,
2nd Sheet White

1000

$42.95

2 Part Continuous
1st Sheet White,
2nd Sheet Canary

1000

$42.95

Discounts available for large quantities.  Contract pricing available.  Call for details.1-877-840-1500

Tentative Timeline for Implementing the Revised Form for Medicare Claims

Medicare anticipates implementing the revised CMS 1500 claim form (version 02/12) as follows:

-  January 6, 2014: Medicare begins receiving and processing paper claims submitted on the revised CMS 1500 claim form (version 02/12).

-  January 6 through March 31, 2014: Dual use period during which Medicare continues to receive and process paper claims submitted on the old CMS 1500 claim form (version 08/05).

-  April 1, 2014: Medicare receives and processes paper claims submitted only on the revised CMS 1500 claim form (version 02/12).

These dates are tentative and subject to change. CMS will provide more information as it is available.

 

 CMS 1500  CLAIM FORMS  (Version 08/05)

We still have the Old HCFA 1500 Forms 12/90 Version (Click Here)

CMS 1500 Forms Laser Cut

Individual Sheets

CMS 1500 Forms Continuous

Continuous

CMS 1500 Forms Snapout

Snapout

CLICK IMAGES TO ENLARGE

TO ORDER
CONTACT US TOLL FREE AT:
1-877-840-1500
8-5 Mon-Fri CST
OR
ORDER SECURE ON-LINE

TOP
OF PAGE

TOP OF PAGE

Description
CMS 1500
 CLAIM FORMS
(Newest Revision)

Quantity/
Case

Price/
Case

CLICK HERE TO

Individual
Sheets

500

$19.99

Individual
Sheets

2500

$35.00

1 Part Continuous

2500

$35.00

2 Part Continuous
1st Sheet White, 2nd Sheet White

1000

$42.95

2 Part Continuous
1st Sheet White, 2nd Sheet Canary

1000

$42.95

Snapout Version

500

$35.00

Discounts available for large quantities.  Contract pricing available.  Call for details.1-877-840-1500

 

 UB04 CLAIM FORMS  (UB04 form replaces UB92 form)

We still have the Old Version UB 92 Forms (Click Here)

UB 04 Forms Laser Cut

Individual Sheets

UB 04 Forms Continuous

Continuous

CLICK IMAGES TO ENLARGE

TO ORDER
CONTACT US TOLL FREE AT:
1-877-840-1500
8-5 Mon-Fri CST
OR
ORDER SECURE ON-LINE

TOP
OF PAGE

TOP OF PAGE

Description
UB04
 CLAIM FORMS
(Replaces UB92)

Quantity/
Case

Price/
Case

CLICK HERE TO

Individual
Sheets

500

$19.99

Individual
Sheets

2500

$35.00

1 Part Continuous

2500

$35.00

2 Part Continuous

1000

$42.95

Discounts available for large quantities.  Contract pricing available.  Call for details.1-877-840-1500

 

 HOME HEALTH FORMS CMS 485, 486 and 487 (HCFA 485, 486, 487)

CMS/HCFA-485 Form

CMS/HCFA-486 Form

CMS/HCFA-487 Form

CLICK IMAGES TO ENLARGE

TO ORDER
CONTACT US TOLL FREE AT:
1-877-840-1500
8-5 Mon-Fri CST
OR
ORDER SECURE ON-LINE

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OF PAGE

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Description
 HOME HEALTH FORMS

Quantity/
Case

Price/
Case

CLICK HERE TO

CMS/HCFA 485
4 Part Continuous

500

$55.00

CMS/HCFA 486
3 Part Continuous

1000

$75.00

CMS/HCFA 487
4 Part Continuous

500

$55.00

Discounts available for large quantities.  Contract pricing available.  Call for details.1-877-840-1500

 

 CLAIM FORM ENVELOPES for CMS/HCFA 1500 Forms, UB04, UB92 Forms

TO ORDER
CONTACT US TOLL FREE AT:
1-877-840-1500
8-5 Mon-Fri CST
OR
ORDER SECURE ON-LINE

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OF PAGE

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Description
 CMS/HCFA 1500
CLAIM FORM ENVELOPES

Quantity/
Case

Price/
Case

CLICK HERE TO

#10 (9-1/2" x 4-1/8") Right Window
ITEM # D38

500

$29.20

NEW! Printed Envelopes
With Your Return Address
#10 (9-1/2" x 4-1/8") Right Window
ITEM # DI38

500

$48.00

Above envelopes are available in right hand window only.
 All envelopes are self-seal and have security liner
.
Your return address can be imprinted in the upper left.
Call for imprinting details.
1-877-840-1500

Discounts available for large quantities.  Contract pricing available.  Call for details.1-877-840-1500

Description
CMS/HCFA 1500
CLAIM FORM ENVELOPES

Qty./
Case

Price/
Case

CLICK HERE TO

9" x 12.5" Right Window
ITEM # D36

500

$89.60

Above envelopes are available in right hand window only.
 All envelopes are self-seal and have security liner
.
Your return address can be imprinted in the upper left.
Call for imprinting details.
1-877-840-1500

Discounts available for large quantities.  Contract pricing available.  Call for details.1-877-840-1500

CMS/HCFA 1500 9"x12.5" Envelope

CLICK IMAGE TO ENLARGE

NEW! - New envelope for the UB04 claim form - NEW!

Description
UB-04
CLAIM FORM ENVELOPES

Quantity/
Case

Price/
Case

CLICK HERE TO

9"x 5-13/16"
ITEM # DUBENVMED

500

Blank - $63.73
Imprinted: $102.77

New envelope for the UB04 claim form. Simply fold the UB04 in half and insert! The envelope has an inside tint for HIPAA compliance and moistenable gum flap..
Your return address can be imprinted in the upper left.
Call for imprinting details.
1-877-840-1500
.

Discounts available for large quantities.  Contract pricing available.  Call for details.1-877-840-1500

 UB-04  9"x 5-13/16" Envelope

Description
UB-04
CLAIM FORM ENVELOPES

Quantity/
Case

Price/
Case

CLICK HERE TO

#10 (9-1/2" x 4-1/8")
Left Window for UB-04
ITEM # DUBENV10
NOT SELF-SEAL

500

$29.20

#10 Envelope for UB04 - Inside tint for HIPAA compliance.
 
Above envelopes are available in left hand window only.
 All envelopes have security liner
.
Your return address can be imprinted in the upper left.
Call for imprinting details.
1-877-840-1500

Discounts available for large quantities.  Contract pricing available.  Call for details.1-877-840-1500

 UB-04 #10 Envelope

Description
UB-04 
CLAIM FORM ENVELOPES

Qty./
Case

Price/
Case

CLICK HERE TO

9" x 12.5" Left Window for UB-04
ITEM # DUB04CAT

500

$89.60

Above envelopes are available in left hand window only.
 All envelopes are self-seal and have security liner
.
Your return address can be imprinted in the upper left.
Call for imprinting details.
1-877-840-1500

Discounts available for large quantities.  Contract pricing available.  Call for details.1-877-840-1500

UB-04  9"x12.5"  Envelope

CLICK IMAGE TO ENLARGE

LOOKING FOR OTHER BUSINESS FORMS?
WE CAN HELP YOU WITH ALL YOUR BUSINESS FORM NEEDS!

TO ORDER CONTACT US TOLL FREE AT:

1-877-840-1500

OR BY FAX:    1-985-809-5788

Our Office Hours are:
  Monday - Thursday:  8am - 5pm CST
Friday:  8am - 12 noon CST

WE ACCEPT VISA, MASTERCARD
and AMERICAN EXPRESS

HOME  |  CMS 1500 (HCFA 1500)  |  UB04 FORMS
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Covington, LA  70433
PHONE:  985-875-0800
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