CMS-1500 Form
8-1/2”W x 11”H snap apart form and is a two part form.
Printed in red, OCR scannable ink in compliance with government standards

The new CMS-1500 (02/12) Health Insurance Claim Form accommodates the reporting of the National Provider Identifier. This new version replaces the old CMS-1500 (08/05) version.

Barcoding is no longer a part of this form.

FREIGHT CHARGES
ACS always confirms to our customers total amount to be charged including freight costs before order
is processed.

RETURNS
There is a 15 day return policy. Customers have 15 days to return products after they have received them. Products are not returnable after this time. Returns are subject to a restocking fee of 25%. If the return is a result of our error, we will issue a call tag. We grant returns on products only if the product and the packaging are in re-sellable condition. Custom products are not returnable.

SALES TAX
ACS charges sales tax if you are a Texas resident, Texas State Sales Tax will be added at the time your
order is invoiced. If you are tax exempt you must provide a Texas Sales Tax Exemption Certificate.