Little Guy Software

Big Guy Software Designed for the Little Guy

ORDERING FORM- for CMS 1500 Forms, UB 04 Forms and Envelopes

All Forms updated for 2015 ICD-10 compatibility

** Note that all of our forms are 100% compliant, printed to exact specs for margins, layout, paper type and ink color.
And we guarantee their compatibility with our software.

Please Read - This ordering form uses Javascript to do calculations automatically.  If you do not have javascript enabled in your web browser, you will need to do the calculations manually, after you complete and print out the form.   You can print the form using 'file' 'print'.  Enter the quantities, shipping costs and totals manually, if they have not calculated and printed automatically.

Please tell us who you are (red denotes required information): NO HANDWRITTEN ORDERS. PLEASE TYPE ALL INFO

SHIP TO ADDRESS:

Name  
Address  
be specific about suite or apartment nos.
City   State Zip Code
Company Name  
Email  
Phone   Other Contact Info:
Returning Customers   I am a Returning Customer     your Customer ID no. please (on your disk or CD)

 ** Note that all forms on this order form are for the NEW CMS (HCFA) 1500 called version 02/12,  and the updated UB 04 form implemented in January, 2014.  They are correct for ICD-10 billing.

  

INSURANCE CLAIM FORMS

quality paper - quality printing

Shipping automatically calculated  if Javascript Enabled

Quantity
Price

subTotal

500 updated CMS 1500 Forms (laser cut sheets for inkjet or laser printers) -  CMS 1500 forms no longer contain Bar-Codes (02/12)

20.00
+ 10.50  S&H each
 

 

1000 updated CMS 1500 Forms (laser cut sheets for inkjet or laser printers) (02/12)

 

30.00
+ 10.50  S&H each
2500 (case) updated CMS 1500 Forms (laser cut sheets for inkjet or laser printers) (02/12)

 

37.50
+ 9.50  S&H each
2500 (case) CONTINUOUS Claim Forms (continuous sheets for tractor feed/pinwheel printers) (02/12)

 

37.50
+ 9.50  S&H each
UB 04 Claim Forms 2500 (case) (laser cut sheets for inkjet or laser printers)
*For smaller quantities (500 or 1000) contact us for pricing

 

37.50
+ 9.50  S&H each
Window Envelopes 500 - Right Hand Window (#10/10.5) Correct for folded CMS forms.
Eliminates the need to print envelopes or make labels. The insurance co. address shows thru the window.

 

38.50
+ 8.50  S&H each
Window Envelopes 500 -  (9X12) - RH window. Correct for unfolded claim forms.
Eliminates the need to print envelopes or make labels. The insurance co. address shows thru the window.

 

89.00
+ 9.00  S&H each
 

Please remember to add shipping and tax (MA residents only) if you are completing this form manually

  TOTAL

 

 

NON Massachusetts Residents ONLY  enter the total sale amount $

---------------------------------------------------------------------------------

Massachusetts Residents   Total sale    $

                                                                                       Must Add 6.25 % Sales Tax -

Amount of sale
Mass Sales Tax
Total Amount Due
Massachusetts Residents Total Enclosed $

payment via check or money order, no credit cards. Contact us via email if you wish to use PayPal.

  Make payable to: little guy software    and send to

little guy software
56 So. Meadow Road
Plymouth, MA  02360

Print this order form from your Print menu or

 

**Click to Print this order form** and send it along with your payment

click here to  
and send payment via US Mail. IF YOU DO NOT GET A CONFIRMATION EMAIL WITHIN A FEW HOURS, WE DID NOT RECEIVE YOUR EMAIL ORDER. You should see your order form load into your email program if the order is successfully going out via email. AOL users should submit the order on paper via US mail. Email orders do not come thru on AOL.

If you have questions or difficulties with this order page,
 please contact us email   sales@littleguysoftware.com

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updated 1/18/2017