Third Party

Claim Forms

Claim Form

Medicare Region

CMS Ins

Remit To

Options

Print Drug Name on Form

Print 1 Patient/Form

Acknowledge Xmit

Default Product Code to NDC

Federal Tax ID

Prescriber Last Name

Display Rx Prescribed Date

Print 'Signature on File' for RPh.

Electronic Form

User ID

Password

Baud Rate

Word Length

Stop Bit

Parity

Primary Phone

Secondary Phone

NOTE: Enter information below ONLY if you want to print something in Box 33 of the CMS 1500 from OTHER THAN the pharmacy information found under System Parameters.

CMS 1500 - Box 33

Name

Address

City

State

ZIP

Phone

Pharmacy

Interchange ID Type

Interchange ID

Application Code

Third Party

Interchange ID Type

Interchange ID

Application Code

NPI

Other ID

Created By/On:Devel# 11/26/2015 | 5:23:47 am

Maintained By/On: PRASHANT 15/12/2018 | 5:06:479 am