Checks & Forms 116 (R) Production time: 1 working day. 1-Part forms; 2,500 per carton and 2-Part forms; 1,000 per carton. Item Number Description 2,500 Popular Pick! VWH-HF4-NS26 Laser ADA Claim Form 2024 Version $102.27 VWH-HF6-NS26 Laser ADA Claim Form 2024 Version for Alaska Medicaid $102.27 VWH-HF1-NS26 1-Part Continuous UB04 form $102.27 VWH-HF3-NS26 Laser UB04 Claim Form $102.27 A. VWH-HF9-NS26 Laser CMS1500 Claim Form 2012 Version $102.27 Claim Forms Item Number Description 1,000 VWH-HF2-NS26 2-Part Continuous UB04 Form $110.93 1 Item Number Description 500 1,000 2,500 5,000 10,000 B. Popular Pick! VWH-H24-NS26 9" x 12" Patient Valuables Envelope, White Heavy Duty Paper $386.53 $766.13 $1,877.20 $3,672.93 $7,196.80 C. VWH-H25-NS26 10" x 13” Patient Valuables Bag, Clear Polyethylene $386.53 $766.13 $1,877.20 $3,672.93 $7,196.80 VWH-H28-NS26 10" x 13” Patient Own Medication bag, Clear Polyethylene $386.53 $766.13 $1,877.20 $3,672.93 $7,196.80 (R) Production time: 1 working day. 500 per carton. Patient Valuables Bags & Envelopes Claim Forms Patient Valuables Envelopes Patient Valuables Bags • 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 • 2,500 per carton (1-Part forms) • 1,000 per carton (2-Part forms) • Guaranteed compliance • 3-Part form/envelope • Tear off receipt on page one for patient to claim their belongings • Consecutively numbered • Heavy-duty paper • Tamper-evident • Imprint color: Reflex Blue • .003 mil low-density polyethylene • Tear off receipt on top for patient to claim their belongings • Consecutively numbered Features A. B. C. Claim Forms & Patient Valuables Bags
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