Manufactured in the USA 122 Claim Forms & Patient Valuables Bags (R) Production time: 1 working day. 1-Part forms; 2500 per carton and 2-Part forms; 1000 per carton. Item Number Description 2,500 VWH-HF5-NS24 Laser ADA Claim Form 2024 Version $80.90 VWH-HF6-NS24 Laser ADA Claim Form 2024 Version for Alaska Medicaid $80.90 VWH-HF1-NS24 1-pt Continuous UB04 form $80.90 VWH-HF3-NS24 Laser UB04 Claim Form $80.90 A. VWH-HF12-NS24 Laser CMS1500 Claim Form 2012 Version $80.90 Claim Forms Item Number Description 1,000 VWH-HF2-NS24 2-Part Continuous UB04 Form $87.51 1 Item Number Description 500 1,000 2,500 5,000 10,000 B. VWH-H24-NS24 9" X 12" Patient Valuables Envelope, White Heavy Duty Paper $305.45 $607.61 $1,484.34 $2,905.94 $5,694.66 C. VWH-H25-NS24 10" X 13” Patient Valuables Bag, Clear Polyethylene $305.45 $607.61 $1,484.34 $2,905.94 $5,694.66 VWH-H28-NS24 10" X 13” Patient Own Medication bag, clear polyethylene $305.45 $607.61 $1,484.34 $2,905.94 $5,694.66 (R) Production time: 1 working day. 500 per carton. Patient Valuables Bags & Envelopes Checks & Forms Claim Forms Patient Valuables Bags Patient Valuables Envelopes • 81/2" x 11" 1-Part forms • 91/2" x 11" 2-Part forms • CMS1500 and UB04 claim forms in OCR Red ink • ADA forms in Black (OCR red for use with Alaska Medicaid claims only) • Most up-to-date forms required for claim submission • 2500 per carton (1-part forms) • 1000 per carton (2-part forms) • Guaranteed compliance • Tamper-evident • Imprint color: Reflex Blue • .003 mil low-density polyethylene • Tear off receipt on top for patient to claim their belongings • Consecutively numbered • 3-part form/envelope • Tear off receipt on page one for patient to claim their belongings • Consecutively numbered • Heavy-duty paper Features NPI NPI 1. MEDICARE 1a. INSURED’S I.D. NUMBER 2. PATIENT’S NAME (Last Name, First Name, Middle Initial) 3. PATIENT’S BIRTH DATE 4. INSURED’S NAME (Last Name, First Name, Middle Initial) 5. PATIENT’S ADDRESS (No., Street) 6. PATIENT RELATIONSHIP TO INSURED 7. INSURED’S ADDRESS (No., Street) ZIP CODE ZIP CODE 9. OTHER INSURED’S NAME (Last Name. First Name, Middle Initial) 10. IS PATIENT’S CONDITION RELATED TO: 11. INSURED’S POLICY GROUP OR FECA NUMBER a. OTHER INSURED’S POLICY OR GROUP NUMBER a. EMPLOYMENT? (Current or Previous) a. INSURED’S DATE OF BIRTH b. RESERVED FOR NUCC USE b. AUTO ACCIDENT? b. OTHER CLAIM ID (Designated by NUCC) c. RESERVED FOR NUCC USE c. OTHER ACCIDENT? c. INSURANCE PLAN NAME OR PROGRAM NAME 10d. CLAIM CODES (Designated by NUCC) d. IS THERE ANOTHER HEALTH BENEFIT PLAN? d. INSURANCE PLAN NAME OR PROGRAM NAME 13. 14. DATE OF CURRENT ILLNESS, INJURY, or PREGNANCY (LMP) 15. 16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES 19. ADDITIONAL CLAIM INFORMATION (Designated by NUCC) 20. OUTSIDE LAB? 21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (Relate A-L to service line below (24E) 22. 25. FEDERAL TAX I.D. NUMBER 26. PATIENT’S ACCOUNT NO. PICA APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12 (For Program in Item 1) INSURED’S OR AUTHORIZED PERSON’S SIGNATURE I authorize payment of medical benefits to the undersigned physician or supplier for services described below. MEDICAID (Medicaid #) TRICARE (ID#/DoD#) CHAMPVA (Member ID#) GROUP HEALTH PLAN (ID#) FECA BLK LUNG (ID#) OTHER (Medicare #) SEX M MM DD YY Self Spouse Child Other TELEPHONE (Include Area Code) ( ) TELEPHONE (Include Area Code) ( ) M F YES NO If yes, complete items 9, 9a and 9d. SIGNED YES NO YES NO YES NO 12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits either to myself or to the party who accepts assignment below. READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM. SIGNED DATE MM DD YY MM DD YY MM DD YY MM DD YY MM DD YY MM DD YY OTHER DATE A. I. YES NO $ CHARGES RESUBMISSION CODE 23. PRIOR AUTHORIZATION NUMBER ORIGINAL REF. NO. A. E. F. $ CHARGES G. H. I. ID. QUAL. J. RENDERING PROVIDER ID. # DATE(S) OF SERVICE B. PLACE OF SERVICE D. PROCEDURES, SERVICES, OR SUPPLIES (Explain Unusual Circumstances) DIAGNOSIS POINTER DAYS OR UNITS EPSDT Family Plan CPT/HCPCS From 24. To MM DD YY MM DD YY 31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS (I certify that the statements on the reverse apply to this bill and are made a part thereof.) SIGNED 32. SERVICE FACILITY LOCATION INFORMATION 27.ACCEPT ASSIGNMENT? (For govt. claims, see back) 28. TOTAL CHARGE 29. AMOUNT PAID $ $ 30. Rsvd for NUCC use 33. BILLING PROVIDER INFO & PH. # PATIENT AND INSURED INFORMATION PHYSICIAN OR SUPPLIER INFORMATION 1 SSN EIN SEX PLACE (State) FROM FROM TO TO (ID#) MM DD YY HEALTH INSURANCE CLAIM FORM PICA F 17b. NPI 2 3 4 5 6 C. EMG MODIFIER YES NO ( ) DATE NPI NPI NPI NPI NPI NPI a. b. a. b. CARRIER CITY 8. RESERVED FOR NUCC USE CITY STATE STATE NUCC Instruction Manual available at: www.nucc.org APPROVED OMB 0938-1197 FORM 1500 (02-12) QUAL. QUAL. ICD Ind. E. B. J. F. C. K. G. D. L. H. PLEASE PRINT OR TYPE WCMS-1500CS-12 SECOND FOLD FIRST FOLD WHCF-10-ENV / WHCF-10-ENV-SS A. B. C.
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