Doctors' Business Forms
PPO FOR HEALTH CARE FORMS
6920 W 79th Street; Overland Park, KS 66204
INSURANCE CLAIM FORMS
CODE
DESCRIPTION
PARTS
CTN. QTY
QTY
PRICE/CTN
HCFA-1500 NPI
Forms for use with laser printers.
1
2,500
$40.00
Continuous tractor-feed carbonless forms
1
2,500
$38.00
2
1,000
$35.00
3
500
$37.00
UB-04
Forms for use with laser printers.
1
2,500
$60.00
Continuous tractor-feed carbonless forms
1
2,500
$45.00
2
1,000
$35.00
3
500
$44.00
4
500
$65.00
SELF-SEAL INSURANCE CLAIM ENVELOPES
HCFA-#10.5
4 1/2" x 9 1/2" with security liner,
STANDARD ADHESIVE RIGHT HAND WINDOW
500
$20.45
4 1/2" x 9 1/2" with security liner,
DRY-GUM SEAL
500
$20.45
HCFA-9x12.5
9" x 12 1/2" with security liner,
STANDARD ADHESIVE RIGHT HAND WINDOW
500
$67.50
No advance payment required. Standard delivery in 2 workdays via UPS. Emergency supplies on hand for immediate delivery. Please call (913) 248-1818 in Kansas City or (800) 530-5894 outside Kansas City. Ask about additional savings on customized items.
RX pads
stationary
appointment cards
superbills
charge tickets
statements
data mailers
window envelopes
return envelopes
Prices show do not include tax or UPS charges, and are subject to change without notice.
Name of Person Ordering
Doctor's Name
Address
City
State
ZIP Code
Phone
Fax