Health Insurance Claim Forms, ALL

Form Number

Description

1492LL		ENV UB92/UB04 HOSP JUMBO LEFT WIN
1500E		ENV CMS SINGLE WINDOW
1500ES		ENV CMS 10 1/2 SELF SEAL
1500LL		ENV CMS 1500 JUMBO LEFT WINDOW
1500LR		ENV CMS 1500 JUMBO RIGHT WINDOW
1500RS		ENV CMS 1500 JUMBO RIGHT-NO STMT
1940		LASER ADA CLAIM 1994
1941		1 PT ADA 1994 CLAIM
1942		2 PT ADA 1994 CLAIM
1994ES		ENV ADA SELFSEAL 94, 90, 87, 85 VER
2000		LASER ADA CLAIM 2000 VERSION
2000ES		ENV ADA SELFSEAL 2000 VERSION
2001		1 PT ADA CLAIM 2000 VER CONT.
2002		2 PT ADA DENTAL 2000 VER
2003ES		ENV ADA SELFSEAL 02, 04, 06 VER.
2300		LASER ADA DENTAL CLM 2002 VERSION
2301		1 PT ADA DENTAL CLM 2002 VERSION
2302		2 PT ADA DENTAL CLM 2002 VERSION
2600		LASER ADA CLAIM 2006
2601		1 PT ADA CLAIM 2006
2602		2 PT ADA CLAIM 2006
485		4 PT HOME HEALTH CERTIFICATION
486		3 PT HOME HEALTH UPDATE
487		4 PT HOME HEALTH ADDENDUM
870		LASER ADA CLAIM FORM '87
871		1 PT ADA CLAIM FORM '87
872		2 PT ADA CLM FORM '87
900		LASER ADA CLM FORM '90 1PT
901		1 PT ADA CLM FORM '90
902		2 PT ADA CLM FORM '90 CONT.
921		1 PT UB-92 CONT.
923		3 PT UB-92 CONTINUOUS
CMS1		1 PT CMS 1500 CONT. 08/05
CMS1B		1 PART CMS 08/05 W/BLOWN ON LABEL
CMS2		2 PT CMS 1500 CONT. 08/05
CMS2B		2 PT CMS WITH B/0 LABEL 08/05
CMS3		3 PT CMS 1500 CONT. 08/05
CMSLC		LASER CMS1500 CUT SHEET (08/05)
CMSLC250		LASER CMS1500 CUT SHEET 250 PER PK
CMSLC500		LASER CMS 1500 CUT SHEET 500/PK
CMSS		SNAPOUT CMS 1500 2 PT 08/05
CMSW2		2 PART CMS1500 CONT. (08/05) W/W
UB041		1 PT UB-04 CONTINUOUS
UB042		2 PT UB-04 CONTINUOUS
UB043		3 PT UB-04 CONTINUOUS
UB044		4 PT UB-04 CONTINUOUS
UB045		5 PT UB-04 CONTINUOUS
UB04LC		LASER UB-04 CUT SHEET

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