To order UB Easy^© complete the order form below and send it along with a check or money order for the correct amount. Sorry, no credit card orders at this time.

The cost of the program is $ 98.50.
Please add $5.00 to all orders for shipping and handling

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ORDERING INFORMATION

PLEASE READ CAREFULLY
to avoid delays in filling your order

Use this form only for ordering.

If you have any pre purchase questions,
go the support page and send an email.

Please complete the form below, print it, include your payment and send it to us snail mail. Your order cannot be filled without this form. Or, if you wish, you may submit the form via email, and then forward your payment. We will not sell or give your name to anyone. Don't forget to give us your email address in case we have any questions about your order and need to contact you.

Please include three unfolded blanks of your UB 92 forms for us to test print for your printer before shipping. Any boxes that are always filled with the same information can be set up to do so automaticaly - just specify what you prefer.

ORDER FORM

Product You Are Ordering -
please click to highlight
UB Easy - UB-92 Form Filler

Your name and title

Company name

Type of organization (i.e., nursing home, hospital, billing agency)

Profession

Your email Address

Street Address (to ship UB Easy to)

Area Code and Phone

Federal Tax No. (for box 5) (required)

Operating System
Windows 95 Windows 98 Windows ME Windows 2000 Windows NT Windows XP

Version of Microsoft Word You Are Using
please click to highlight
Microsoft Word 97 (Office 97) Microsoft Office 2000 Microsoft Office XP Microsoft Office 2003

Make, model and type (tractor feed, inkjet or laser) of Printer

Any additional info or boxes you'd like the program
to complete automatically - for example, the content of box 1.

For quick delivery, check to request we send you the program
as a very easy to install download from our web site.

Where did you learn about our program?
Google Yahoo MSN AOL ALTA VISTA Ask Jeeves Colleague Other If Other, please specify

and send payment and 3 unfolded blank UB 92 forms
(the ones you are using for us to test print on) snail mail

The cost of UB Easy Form Filler^© is

$98.50 plus $5.00

shipping and handling
to receive the program on disk

Make check payable to K.L. Laytin, PhD

send payment, order form and 3 unfolded blanks to

UB EASY / EASY HCFA Form Filler
56 So. Meadow Road
Plymouth, MA 02360

updated 02/15/04