Click here to return to DMC home page

HCFA-1500 and UB-92
Insurance Claim Forms

The Health Care Finance Administration requires that all insurance claims to be submitted on form HCFA-1500. In strict compliance with government printing specifications the forms are printed using specified bond paper. It can be purchased with or without a bar code, which may or may not be required by some health agencies.

You may purchase HCFA -1500 in a variety of styles, The standard HCFA -1500 is available in continuous and laser cut sheet form. The continuous form can be purchased in 1 part, 2 part and 3 part formats.

For special application and needs the can also be purchased with pre-attached self imaging labels. The Medicare faxable HCFA -1500 (printed in green ink) is also available.
 
Insurance Form Pricing

HCFA 1500's
# of plys case qty. 1-2 cases 3-5 cases 6-10 cases 10 + cases
one 2500 50.00/cs 45.00/cs 39.00/cs 35.00/cs
two 1000 54.00/cs 49.00/cs 42.00/cs 38.00/cs
three 500 49.00/cs 43.00/cs 37.00/cs 34.00/cs
cut sheet 2500 65.00/cs 59.00/cs 50.00/cs 46.00/cs
2 pt snap 500 44.00/cs 39.00/cs 30.00/cs 26.00/cs
UB-92's
# of plys case qty 1-2 cases 3-5 cases 6-10 cases 10+ cases
one 2500 51.00/cs 43.00/cs 39.00/cs 36.00/cs
two 1000 53.00/cs 46.00/cs 42.00/cs 38.00/cs
three 500 49.00/cs 42.00/cs 37.00/cs 33.00/cs
four 500 54.00/cs 48.00/cs 44.00/cs 40.00/cs
five 500 64.00/cs 59.00/cs 55.00/cs 50.00/cs
cut sheet 2500 61.00/cs 56.00/cs 52.00/cs 48.00/cs
Dental Claim Forms
style case qty 1-2 cases 3-5 cases 6-10 cases 10+ cases
83 rev 1pt 2500 64.00/cs 58.00/cs 54.00/cs 51.00/cs
83 rev 2pt 1000 51.00/cs 43.00/cs 40.00/cs 36.00/cs
90 rev 1pt 2500 69.00/cs 64.00/cs 61.00/cs 58.00/cs
90 rev 2pt 1000 51.00/cs 43.00/cs 40.00/cs 36.00/cs
94 rev 2pt 1000 51.00/cs 43.00/cs 40.00/cs 36.00/cs
94 rev cut 2500 61.00/cs 55.00/cs 51.00/cs 47.00/cs
 
  • Data management maintains multiple shipping points with facilities in Wisconsin, Pennsylvania, Georgia, California, and Texas
  • All orders placed before 11:00 am central time will ship on the same day.
  • Please call for current pricing.
  • Envelopes for HCFA forms are also available.

For Assistance, or questions on Insurance Forms:
Call 1-800-873-6910, or (262) 783-6910
Monday - Friday, 8:00am - 5:00pm, Central Standard Time (USA)
or email us!

Home