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Site Updated
Monday, June 30, 2008



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Supplies - Claim Forms
MED-PASS offers a complete line of CMS claim forms in addition to other types of claim forms including Universal claim forms. MED-PASS claim forms are priced very competitively to provide the convenience of one-stop-shopping and help reduce your billing costs.

MED-PASS CMS claim forms are in strict compliance with government printing specifications to ensure acceptance and efficient processing.

If the claim form you need is not listed below, or you need assistance, contact MED-PASS customer service at 800-438-8884.

CMS-1450 (UB04 and UB92)
ST11842

CMS 1450 Claim Form (UB-92), Laser, 1 part, White paper, Red (OCR) ink - DISCONTINUED

ST11842N

CMS 1450 Claim Form (UB-04), Laser, 1 part, White paper, Red (OCR) ink

ST11843

CMS 1450 Claim Form (UB-92), Continuous, 1 part, White paper, Red (OCR) ink - DISCONTINUED

ST11843N

CMS 1450 Claim Form (UB-04), Continuous, 1 part, White paper, Red (OCR) ink

ST11844

CMS 1450 Claim Form (UB-92), Continuous, 2 part, White/White paper, Red (OCR) ink - DISCONTINUED

ST11844N

CMS 1450 Claim Form (UB-04), Continuous, 2 part, White/White paper, Red (OCR) ink

ST11845

CMS 1450 Claim Form (UB-92), Continuous, 3 part, White paper, Red (OCR) ink - DISCONTINUED

ST11845N

CMS 1450 Claim Form (UB-04), Continuous, 3 part, White paper, Red (OCR) ink

ST11846

CMS 1450 Claim Form (UB-92), Continuous, 4 part, White paper, Red (OCR) ink - DISCONTINUED

ST11846N

CMS 1450 Claim Form (UB-04), Continuous, 4 part, White paper, Red (OCR) ink

CMS-1500
1500LR

Jumbo CMS 1500 Envelope, Right Window

ST11741N

CMS 1500 (08/05) Claim Form, Continuous, 3 part, White/Canary/Pink paper, Red (OCR) ink

ST11742

CMS 1500 Claim Form With Bar Code, Continuous, 3 part, White/Canary/Pink paper, Red (OCR) ink DISCONTINUED

ST11774

CMS 1500 Claim Form NO Bar Code, Continuous, 1 part, White paper, Red (OCR) ink DISCONTINUED

ST11776

CMS 1500 Claim Form NO Bar Code, Continuous, 2 part, White/White paper, Red (OCR) ink DISCONTINUED

ST11777

CMS 1500 Claim Form NO Bar Code, Continuous, 2 part, White/Canary paper, Red (OCR) ink DISCONTINUED

ST11778

CMS 1500 Claim Forms With Bar Code, Continuous, 2 part, White/Canary paper, Red (OCR) ink DISCONTINUED

ST11778N

CMS 1500 (08/05) Claim Forms, Continuous, 2 part, White/Canary paper, Red (OCR) ink

ST11781

CMS 1500 Claim Form NO Bar Code, Laser, 1 part, White paper, Red (OCR) ink DISCONTINUED

ST11782

CMS 1500 Claim Forms With Bar Code, Continuous, 1 part, White paper, Red (OCR) ink DISCONTINUED

ST11782N

CMS 1500 (08/05) Claim Forms, Continuous, 1 part, White paper, Red (OCR) ink

ST11783

CMS 1500 Claim Form NO Bar Code, Continuous, 1 part, White paper, Red (OCR) inkDISCONTINUED

ST11784

CMS 1500 Claim Form With Bar Code, Continuous, 2 part, White/White paper, Red (OCR) inkDISCONTINUED

ST11784N

CMS 1500 (08/05) Claim Form, Continuous, 2 part, White/White paper, Red (OCR) ink

ST11785

CMS 1500 Claim Form With Bar Code, 32mm from top,Laser, 1 part, White paper, Red (OCR) ink DISCONTINUED

ST11786

CMS 1500 Claim form With Bar Code, Laser, 1 part, White paper, Red (OCR) ink DISCONTINUED

ST11786N

CMS 1500 (08/05) Claim form, Laser, 1 part, White paper, Red (OCR) ink

Universal Claim Forms
5-1202

Universal Claim Form

5-1203

Universal Claim Form Laser Format

Miscellaneous
HCFA485

Home Health Certification and Plan of Care, Continuous, 4 part

HCFA486

Medical Update and Patient Information, Continuous, 3 part

HCFA487

Home Health Addendum, Continuous, 4 part

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800-438-8884