EASY HCFA 1500 Plus ($124.50)
Here is what we provide:
The software you will receive 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. Contact us if you are interested in a Group Version of this product.
Complete the ordering information below and we will contact you and provide you with our toll-free number
Profession: Psychologist Physician Psychiatrist Social Worker Licensed Mental Health Counselor Speech Pathologist Psychiatric Nurse Pharmacy Surgical Assistant Physical Therapist Occupational Therapist Home Health Care Provider Medical Supply Company Billing or Claims Service Other
Your email Address
Area Code and Phone
Street Address (to ship EASY HCFA 1500 to)
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 or Your social security number
Provider Numbers (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? Colleague Internet Search Engine Printed Advertisement Other please specify search engine
Best time and method to contact you. Please indicate your time zone.
EXTENDED SPECIAL OFFER Order EASY HCFA Plus 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. Are we shipping to a residence or in-home office?
Are we shipping to a residence or in-home office?
EASY HCFA Plus = $124.50
500 HCFA / CMS 1500 Forms = $20.00 & $2.50 S&H
Checks must be made payable to K.L. Laytin, PhD and mailed to:
Please remember to send three unfolded original blank forms unless you are purchasing forms from us.
Go to FILE, PRINT to print this ordering form or