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Your cart is empty.Approved by the National Uniform Claim Committee (NUCC); HIPAA compliant. This form was revised to align the paper form with some of the changes in the electronic health care claims: Professional (837), 005010X222 Technical Report Type 3 (5010) and 005010X222A1 Technical Report Type 3 (5010A1). The most significant change was the addition of 8 diagnosis codes in field 21. Includes new QR code identifier at the top of the form that supports and aligns with Industry scanning systems. Printed with OCR "dropout" red ink on 20 pounds. paper (per government regulations). Form not available personalized. Certified Chain of Custody; promotes sustainable forest management. Size: 8-1/2x11".
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