87
READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.
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.
13. INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I
payment of medical benefits to the undersigned physician o
services described below.
SIGNED
DATE
SIGNED
aut
r supp
SIGN-IN SHEET
14037 Salmon
(250/pkg)
18229 Green
(250/pkg)
18228 Blue
(250/pkg)
17017 Fish
(100/pkg)
17014 Toothbrush
(100/pkg)
17008 Smile
(100/pkg)
Submission Envelopes
The window placement is specifically designed to have the insurance carrier’s name
and address show through the window (provided your computer prints out the
insurance carrier’s name and address in the upper right-hand corner.)
Available in regular moist & seal or convenient self-seal,
both have security interior tint. Right hand window.
HC10RG
Regular (9-1/2" x 4-1/8") Blank (500/box)
HC10SS
Self-Seal (9-1/2" x 4-1/8") Blank (500/box)
Jumbo insurance envelope is designed to accommodate
up to 50 insurance claims to the same carrier.
HC912
Side-Seal HCFA Envelopes (9" x 13") (100/pkg.)
Insurance Signature Release Labels
Save time by having patient sign several of these labels on their first visit. They can be used for
subsequent claims as needed. Compatible with HCFA-1500 forms.
7891HL
– 5/8" H x 7" W Self Adhesive Label (375 Labels per pack. 15 Labels per sheet)
HCFA Approved Medical Insurance Forms
All forms are government approved HCFA-1500 to serve federal programs and private insurers as a universal claim form.
The 2- part form is carbonless. Revision (08-05)
Item
Description
Carton Qty
79109NPI
Cut Sheet
1000
79259NPI
Cut Sheet
2500
79106NPI
Continuous Sheet
1000
79256NPI
Continuous Sheet
2500
79120NPI
2-Part Continuous
1000
IFS_Catalog_Sept_2011_Body_V5.indd 87
9/18/11