Individual Custom Version ($43.50) is sold only to individual clinical practitioners or small group practices of 3 or fewer practitioners. We require the individual practitioner's name, the Group Practice name, or the names of the members of the Group (3 maximum) which will be permanently build into the first line of box 33. We will personalize your version of EASY HCFA 1500 Form Filler™ so that your address, telephone, provider ID number(s), professional license number and "Signature on File" (for boxes 12 and 13) are printed automatically. If you deal with multiple HMOs and have more than one provider number, each of those can be entered on the form by pointing and clicking at the correct choice on a drop down menu. This version also includes the ability to enter the insurance co. name and address at the top of the form allowing use of a window envelope.
Group Version ($98.50) has all of the flexible features of the Custom Version but is designed for group practices of more than 3 practitioners, Clinics, Billing Services and businesses such as Government Agencies, Hospitals, Medical Equipment Supply Companies, Optical Supply Companies, Universities, Medical Laboratories, Health Service Agencies, Fire (ambulance) Companies, Home Nursing Services, Schools, Home Health Care Agencies, Day Care Facilities, Pharmacies, etc. Such organizations must purchase this version. If you wish, we can personalize this version of EASY HCFA 1500 Form Filler™ so that your address, telephone, provider ID number(s), professional license number and "Signature on File" (for boxes 12 and 13) are printed automatically. If you deal with multiple HMOs and have more than one provider number, each of those can be entered on the form by pointing and clicking at the correct choice on a drop down menu. This version also includes the ability to enter the insurance co. name and address at the top of the form allowing use of a window envelope.
Your email Address
Area Code and Phone
NAME and Street Address (to ship EASY HCFA 1500 to) Please make certain the address is detailed (i.e., suite #s), correct and complete. UPS surcharges are incurred when the shipping address is not accurate.
this is a Business Address this is a Residential Address (UPS considers an in-home office to be a residence)
Program To Be Used By:
(this item MUST be completed) (1)- Individual Clinical Practitioner (2)- Small Group Clinical Practice (3 or less) (3)- Large Group, Billing/Claims Service, Pharmacy, Govt. Agency, Home Health or Day Care, Medical Supply co. Fire/Ambulance Services, Nursing Home, Hospital, Clinic, etc.
Customizing at no additional charge
Your Title and License no. (BOX 31)
Supplier's Billing Name, Address, Zip (BOX 33)
Supplier's Phone number for BOX 33
Your employer ID (EIN) or
Provider Numbers (PIN #s) for BOX 33 for drop down menu - list all nos. you use - most frequent first.
Group Numbers (GRP #s) for BOX 33 for drop down menu - list all nos. you use - most frequent first.
Any additional issues or requirements Note that box 24D, the procedure codes, is always set up as a fill-in
Where did you learn about our program? Google Yahoo MSN AOL ALTA VISTA Ask Jeeves Colleague Other If Other, please specify
Individual Custom Version** = $43.50
Group Version** = $98.50
I have enclosed an additional $5.00 to cover shipping and handling as I prefer software delivery on a 3 .5 inch diskette
If you are also ordering claim forms or envelopes
Tell us the Product Numbers and the no. of cases you are ordering; Additional Product Numbers and the no. of cases you are ordering; Total cost of the forms including shipping and handling Total amount you have enclosed
** Software price includes a really easy delivery via download from our web site. ** You will be notified via email when your program has been completed and is available to you for download. That email will include easy download instructions.
EXTENDED SPECIAL OFFER Order either version of EASY HCFA 1500 on disk ($48.50 or $103.50) and get 500 high quality laser cut bar coded (check for bar coded) HCFA 1500 forms or 500 high quality laser cut non bar coded (check for non bar coded) for only $20.00 additional and only $2.50 shipping charges for the forms ! (in the 48 contiguous states) Your program will be aligned to your new forms. That's the Individual Custom Version on disk plus 500 forms for only $68.50 or the Group Version on disk plus 500 forms for only $123.50 Plus add only $2.50 for UPS shipping. All Checks must be made payable to K.L. Laytin, PhD
That's the Individual Custom Version on disk plus 500 forms for only $68.50 or the Group Version on disk plus 500 forms for only $123.50 Plus add only $2.50 for UPS shipping.
and mailed to:
Because of the great response to EASY HCFA 1500 Form Filler, please allow 10-14 days after we receive payment for your software to be shipped. Claim forms ship faster Please remember to send three unfolded original blank forms if you are ordering our software UNLESS you are buying our laser cut bar code forms.
TO PRINT THIS FORM go to File, Print or
**AOL users: Forms submitted via AOL's email often come through without their content. Please print the order form and send it snail mail. Thanks.