UB04 Forms & Envelopes. Healthcare Forms

Transcription

1 U0 Forms & Envelopes Helthcre Forms

2 Tle of ontents MS 1500 Forms MS 1500 Envelopes U0 Forms & Envelopes Dentl lim Forms & Envelopes Shred Medicl System ills Prescription Pper: Lser Sheets Prescription Pper: Direct Therml Secure Prescription: Direct Therml Printer Lser hecks Imge Sel hecks Dischrge Folders Our compny is proud of our long-stnding commitment to helthcre. Founded more thn 100 yers go, our dediction to helthcre dtes ck to 1928 when Stndrd Register founder John Q. Shermn led community drive to rise $1 million in 30 dys to uild Dyton s Good Smritn Hospitl. Since then, we hve een devoted to improving ptient cre. Every dy, our tem of more thn 175 dedicted helthcre professionls work side-y-side with clinicins nd stff to enhnce ptient enggement nd the qulity of cre. In short, we re dedicted to mking helthcre etter. cquired y Tylor orportion in 2015, Tylor Helthcre, prt of Tylor ommunictions, Inc., is mrketing nd communictions compny serving the helthcre industry with rod spectrum of tngile nd digitl solutions primrily in the cute, long-term cre nd pyer mrkets. We help our customers stndrdize nd mnge communictions cross the continuum of cre, enling them to engge ptients nd fmilies with the right informtion t the right time to influence ehvior nd improve outcomes.

3 PPROVED Y NTIONL UNIFORM LIM OMMITTEE (NU) 02/12 1. MEDIRE MEDIID TRIRE HMPV GROUP FE OTHER 1. INSURED S I.D. NUMER HELTH PLN LK LUNG (Medicre #) (Medicid #) (ID#/DoD#) (Memer ID#) (ID#) (ID#) (ID#) 2. PTIENT S NME (Lst Nme, First Nme, Middle Initil) 3. PTIENT S IRTH SEX. INSURED S NME (Lst Nme, First Nme, Middle Initil) MM DD YY M F 5. ITY PTIENT S ZIP DDRESS (No., Street) 6. PTIENT RELTIONSHIP TO INSURED 7. INSURED S ZIP DDRESS 9. OTHER INSURED S NME (Lst Nme. First Nme, Middle Initil) 10. IS PTIENT S ONDITION RELTED TO: 11. INSURED S POLIY GROUP OR FE NUMER. OTHER INSURED S POLIY OR GROUP NUMER. EMPLOYMENT? (urrent or Previous) (No.,. INSURED S OF IRTH MM DD YY. RESERVED FOR NU USE. UTO IDENT? PLE (Stte). OTHER LIM ID (Designted y NU) c. RESERVED FOR NU USE d. INSURNE PLN NME OR PROGRM NME 1. MM 21. PI DIGNOSIS OF URRENT DD YY OR NTURE ILLNESS, OF TELEPHONE (Include re ode) INJURY, ILLNESS or PREGNNY OR INJURY. Relte (LMP) -L to 15. c. service OTHER IDENT? Street) c. INSURNE PLN NME OR PROGRM NME 10d. LIM S (Designted y NU) d. IS THERE NOTHER HELTH ENEFIT PLN? line elow (2E) 25. FEDERL TX I.D. NUMER SSN EIN 26. PTIENT S OUNT NO. Self Spouse hild Other RED K OF FORM EFORE OMPLETING & SIGNING THIS FORM. 12. PTIENT S OR UTHORIZED PERSON S SIGNTURE I uthorize the relese of ny medicl or other informtion necessry to process this clim. I lso request pyment of government enefits either to myself or to the prty who ccepts ssignment elow.. E. SIGNED OTHER YES YES YES MM DD NO NO NO YY 13. INSURED S OR UTHORIZED PERSON S SIGNTURE I uthorize pyment of medicl enefits to the undersigned physicin or supplier for services descried elow S PTIENT UNLE TO WORK MM DD YY FROM IN URRENT MM TO (For Progrm in Item 1) TELEPHONE (Include re ode) YES NO If yes, complete items 9, 9 nd 9d. SIGNED YES RESUMISSION I. J. K. L. 2.. (S) OF SERVIE.. D. PROEDURES, SERVIES, OR SUPPLIES E. F. From To PLE OF (Explin Unusul ircumstnces) DIGNOSIS MM DD YY MM DD YY SERVIE EMG PT/HPS MODIFIER POINTER $ HRGES 31. SIGNTURE OF PHYSIIN OR SUPPLIER INLUDING DEGREES OR REDENTILS (I certify tht the sttements on the reverse pply to this ill nd re mde prt thereof.) SIGNED QUL.. F. STTE. G. QUL NPI RESERVED FOR NU USE ID Ind. 32. SERVIE FILITY LOTION INFORMTION D. H. YES NO DD NO 23. PRIOR UTHORIZTION NUMER M MM $ HRGES ORIGINL REF. NO. G. H. I. DYS EPSDT ID. OR Fmily UNITS Pln QUL. NPI 28. TOTL HRGE 29. MOUNT PID $ FROM 33. ILLING PROVIDER INFO & PH. #.... ITY $ NPI NPI NPI NPI NPI TO SEX F PI STTE OUPTION DD YY YY J. RENDERING PROVIDER ID. # 30. Rsvd for NU use MS 1500 Forms U0 Forms & Envelopes HELTH INSURNE LIM FORM RRIER SEOND FOLD FIRST FOLD WHF-10-ENV / WHF-10-ENV-SS ( ) 17. NME OF REFERRING PROVIDER OR OTHER SOURE HOSPITLIZTION S RELTED TO URRENT SERVIES MM YY DD 19. DDITIONL LIM INFORMTION (Designted y NU) 20. OUTSIDE L? 27. EPT SSIGNMENT? (For govt. clims, see ck) ( ) PTIENT ND INSURED INFORMTION PHYSIIN OR SUPPLIER INFORMTION ( ) NPI NPI NU Instruction Mnul ville t: PLESE PRINT OR TYPE PPROVED OM FORM 1500 (02-12) WMS-1500S-12 MS 1500 lim Form Version 02/12 Prt Numer Type Quntity Pper MS12L Lser Sheet 2500 per rton 20# White, 8 1/2 x 11 MS121 ontinuous 1-ply 2500 per rton 20# White, 9 1/2 x 11 MS122 ontinuous 2-ply 1000 per rton 21# ron White 15# F nry, 9 1/2 x 11 MS12W2 ontinuous 2-ply 1000 per rton 21# ron White 15# F White, 9 1/2 x 11 MS123 ontinuous 3-ply 500 per rton 21# ron White 15# F nry 15# F Pink, 9 1/2 x 11 MS121 ontinuous with lown On Lel 1-ply 1000 per rton 20# White, 9 1/2 x 11 MS122 ontinuous with lown On Lel 2-ply 1000 per rton 21# ron White 15# F nry, 9 1/2 x 11 Tylor Helthcre Forms tlog 3

4 MS 1500 Envelopes 1500RS 1500LR 1500ES MS 1500 lim Form Miling Envelopes Prt Numer Description Quntity Forms Per Envelope 1500ES #10-1/2 Self Sel 500 Holds up to 12 folded clims 1500E #10-1/2 Gum Sel 500 Holds up to 12 folded clims 1500LR 9x12-1/2 Jumo Right Window Self Sel Printed Insurnce Forms Included 500 Holds up to 50 unfolded clims 1500RS 9x12-1/2 Jumo Right Window Self Sel-No Printing 500 Holds up to 50 unfolded clims Tylor Helthcre Forms tlog

5 G M O PT. NTL # 8 PTIENT NME 10 IRTH 11 SEX DMISSION HR 1 TYPE 15 SR 9 PTIENT DDRESS 16 DHR 17 STT. MED. RE. # 5 FED. TX NO. ONDITION S STTEMENT OVERS PERIOD FROM THROUGH c d 29 DT STTE 30 7 TYPE OF ILL e PT. NTL # 31 OURRENE 32 OURRENE 33 OURRENE 3 OURRENE 35 OURRENE SPN 36 OURRENE SPN 37 FROM THROUGH. MED. FROM THROUGH RE. # 5 FED. TX NO. 6 STTEMENT OVERS PERIOD 7 FROM THROUGH VLUE S 0 VLUE S 1 VLUE S MOUNT MOUNT 8 PTIENT NMEMOUNT 9 PTIENT DDRESS c d e 10 IRTH 11 SEX DMISSION ONDITION S HR 1 TYPE 15 SR 16 DHR 17 STT 29 DT c d 31 OURRENE 32 OURRENE 33 OURRENE 3 OURRENE 35 OURRENE SPN 36 OURRENE SPN 37 FROM THROUGH FROM THROUGH 2 REV. D. 3 DESRIPTION HPS / RTE / HIPPS 5 SERV. 6 SERV. UNITS 7 TOTL HRGES 8 NON-OVERED HRGES VLUE S 0 VLUE S 1 VLUE S MOUNT MOUNT MOUNT 3 3 G 5 5 c 6 6 M d REV. D. 3 DESRIPTION HPS / RTE / HIPPS 5 SERV. 6 SERV. UNITS 7 TOTL HRGES 8 NON-OVERED HRGES O REL. 53 SG. 50 PYER NME 51 HELTH PLN ID 5 PRIOR PYMENTS 55 EST. MOUNT DUE 56 NPI INFO EN OTHER PRV ID INSURED S NME 59 P. REL 60 INSURED S UNIQUE ID 61 GROUP NME 62 INSURNE GROUP NO REL. 53 SG. 50 PYER NME 51 HELTH PLN ID 5 PRIOR PYMENTS 55 EST. MOUNT DUE 56 NPI 63 TRETMENT UTHORIZTION S 6 DOUMENT ONTROL NUMER 65 EMPLOYER NME INFO EN. 57 OTHER PRV ID INSURED S NME P. REL 60 INSURED S UNIQUE ID 61 GROUP NME 62 INSURNE GROUP NO. DX DMIT 70 PTIENT 71 PPS DX RESON DX EI 7 PRINIPL PROEDURE. OTHER PROEDURE. OTHER PROEDURE TTENDING NPI QUL 63 TRETMENT UTHORIZTION S 6 DOUMENT ONTROL NUMER 65 EMPLOYER NME LST FIRST c. OTHER PROEDURE d. OTHER PROEDURE e. OTHER PROEDURE 77 OPERTING NPI QUL LST FIRST REMRKS 78 OTHER NPI QUL LST FIRST c 79 OTHER NPI QUL 69 DMIT 70 PTIENT 71 PPS d LST FIRST DX RESON DX EI U-0 MS-150 F-U0-1 PPROVED OM NO OR/Originl THE ERTIFITIONS ON THE REVERSE PPLY TO THIS 7 ILL ND PRINIPL RE MDE PROEDURE PRT HEREOF.. OTHER PROEDURE. OTHER PROEDURE 75 Ntionl Uniform 76 TTENDING NPI QUL illing ommittee LST FIRST c. OTHER PROEDURE d. OTHER PROEDURE e. OTHER PROEDURE 77 OPERTING NPI QUL LST FIRST REMRKS 78 OTHER NPI QUL LST FIRST c 79 OTHER NPI QUL d LST FIRST U-0 MS-150 F-U0-1 PPROVED OM NO OR/Originl THE ERTIFITIONS ON THE REVERSE PPLY TO THIS ILL ND RE MDE PRT HEREOF. Ntionl Uniform illing ommittee TYPE OF ILL U0 Forms & Envelopes 5 5 STTE PGE OF RETION TOTLS I J K L D M E N F O G P H Q c c PGE OF RETION TOTLS F-U0-1 5 DX 67 I J K L D M E N F O G P H Q c c U0L F-U0-1 5 U01, U02, U03 U0 illing Forms formerly HF or MS150 Prt Numer Type Quntity Pper U0L Lser Sheet 2500 per rton 20# White, 8 1/2 x 11 U01 ontinuous 1-ply 2500 per rton 20# White, 9 1/2 x 11 U02 ontinuous 2-ply 1000 per rton 21# ron White 15# F nry, 9 1/2 x LL 2003ES U-0 illing Form Miling Envelopes Prt Numer Description Quntity Forms Per Envelope 192LL 9x12-1/2 Jumo Left Window Self Sel-Insurnce lim Forms Enclosed 500 Holds up to 50 unfolded clims 2003ES -1/8x9 Window Envelope Self Sel 500 Holds up to 12 folded clims Tylor Helthcre Forms tlog 5

6 fold fold HEDER INFORmTION 1. Type of Trnsction (Mrk ll pplicle oxes) Sttement of ctul Services Request for Predetermintion/Preuthoriztion EPSDT / Title XIX 2. Predetermintion/Preuthoriztion Numer POlIyHOlDER/SUSRIER INFORmTION (For Insurnce ompny Nmed in #3) 12. Policyholder/Suscrier Nme (Lst, First, Middle Initil, Suffix), ddress, ity, Stte, Zip ode HEDER INFORMTION INSURNE OmPNy/DENTl ENEFIT PlN INFORmTION 1. Type of Trnsction (Mrk ll pplicle oxes) 3. ompny/pln Nme, ddress, ity, Stte, Zip ode Sttement of ctul Services Request for Predetermintion/ Preuthoriztion EPSDT/ Title XIX 2. Predetermintion/ Preuthoriztion Numer POLIYHOLDER/SUSRIER INFORMTION (For Insurnce ompny Nmed in #3) 13. Dte of irth (MM/DD/YY) 1. Gender 15. Policyholder/Suscrier ID (SSN or ID#) 12. Policyholder/Suscrier Nme (Lst, First, Middle Initil, Suffix), ddress, ity, Stte, Zip ode M F INSURNE OMPNY/DENTL ENEFIT PLN INFORMTION OTHER OVERgE (Mrk pplicle ox nd complete items If none, leve lnk.) 16. Pln/Group Numer 17. Employer Nme 3. ompny/pln Nme, ddress, ity, Stte, Zip ode. Dentl? Medicl? (If oth, complete 5-11 for dentl only.) 5. Nme of Policyholder/Suscrier in # (Lst, First, Middle Initil, Suffix) PTIENT INFORmTION 18. Reltionship to Policyholder/Suscrier in #12 ove 19. Reserved For Future Use 13. Dte of irth (MM/DD/YY) 1. Gender 15. Policyholder/Suscrier ID (SSN or ID#) 6. Dte of irth (MM/DD/YY) 7. Gender 8. Policyholder/Suscrier ID (SSN or ID#) Self Spouse Dependent hild Other M F M F 20. Nme (Lst, First, Middle Initil, Suffix), ddress, ity, Stte, Zip ode OTHER OVERGE 16. Pln/Group Numer 17. Employer Nme 9. Pln/Group Numer 10. Ptient s Reltionship to Person nmed in #5. Other Dentl or Medicl overge? No (Skip 5-11) Yes (omplete 5-11) Self Spouse Dependent Other 5. Nme of Policyholder/Suscrier in # (Lst, First, Middle Initil, Suffix) PTIENT INFORMTION 11. Other Insurnce ompny/dentl enefit Pln Nme, ddress, ity, Stte, Zip ode 18. Reltionship to Policyholder/Suscrier in #12 ove 19. Student Sttus 6. Dte of irth (MM/DD/YY) 7. Gender 8. Policyholder/Suscrier ID (SSN or ID#) Self Spouse Dependent hild Other FTS PTS 21. Dte of irth (MM/DD/YY) 22. Gender 23. Ptient ID/ccount # (ssigned y Dentist) M F 20. Nme (Lst, First, Middle Initil, Suffix), ddress, ity, Stte, Zip ode M F 9. Pln/Group Numer 10. Ptient s Reltionship to Person Nmed in #5 REORD OF SERVIES PROVIDED Self Spouse Dependent Other 25. re Procedure Dte 27. Tooth Numer(s) 28. Tooth 29. Procedure 29. Dig. 29. of Orl Tooth 30. Description 31. Fee (MM/DD/YY) or Letter(s) Surfce ode Pointer Qty. 11. Other Insurnce ompny/dentl enefit Pln Nme, ddress, ity, Stte, Zip ode vity System Dte of irth (MM/DD/YY) 22. Gender 23. Ptient ID/ccount # (ssigned y Dentist) 3 M F REORD OF SERVIES PROVIDED 5 2. Procedure Dte 25. re Tooth Numer(s) 28. Tooth 29. Procedure of Orl Tooth (MM/DD/YY) or Letter(s) 30. Description 31. Fee 6 vity System Surfce ode Missing Teeth Informtion (Plce n X on ech missing tooth.) 3. Dignosis ode List Qulifier ( ID-9 = ; ID-10 = ) Other Fee(s) Dignosis ode(s) (Primry dignosis in ) D Totl Fee 35. Remrks 8 9 UTHORIZTIONS NIllRy lim/tretment INFORmTION I hve een informed of the tretment pln nd ssocited fees. I gree to e responsile for ll 39. MISSING Enclosures TEETH (Y or N) INFORMTION Permnent Primry 32. Other chrges for dentl services nd mterils not pid y my dentl enefit pln, unless prohiited y (Use Plce of Service odes for Professionl lims ) lw, or the treting dentist or dentl prctice hs contrctul greement with my pln prohiiting ll D E F G H I J Fee(s) 3. (Plce n 'X' on ech missing tooth) or portion of such chrges. To the extent permitted y lw, I consent to your use nd disclosure 0. Is Tretment for Orthodontics? 1. Dte pplince Plced (MM/DD/YY) T S R Q P O N M L K 33.Totl Fee of my protected helth informtion to crry out pyment ctivities in connection with this clim. No (Skip 1-2) Yes (omplete 1-2) 35. Remrks Ptient/Gurdin Signture Dte 2. Months of Tretment 3. Replcement of Prosthesis. Dte of Prior Plcement (MM/DD/YY) Remining No Yes (omplete ) 37. I herey uthorize nd direct pyment of the dentl enefits otherwise pyle to me, directly UTHORIZTIONS NILLRY LIM/TRETMENT INFORMTION to the elow nmed dentist or dentl entity. 5. Tretment Resulting from 36. I hve een informed of the tretment pln nd ssocited fees. I gree to e responsile for ll 38. Plce of Tretment 39. Numer of Enclosures (00 to 99) chrges for dentl services nd mterils not pid y my dentl enefit pln, unless prohiited y lw, or Rdiogrph(s) Orl Imge(s) Model(s) Occuptionl illness/injury uto ccident the treting Other dentist ccident or dentl prctice hs contrctul greement with my pln prohiiting ll or portion of Provider s Office Hospitl EF Other such chrges. To the extent permitted y lw, I consent to your use nd disclosure of my protected helth Suscrier Signture Dte 6. Dte of ccident (MM/DD/YY) informtion 7. uto crry ccident out pyment Stte ctivities in connection with this clim. 0. Is Tretment for Orthodontics? 1. Dte pplince Plced (MM/DD/YY) IllINg DENTIST OR DENTl ENTITy (Leve lnk if dentist or dentl entity is not TRETINg DENTIST ND TRETmENT lotion INFORmTION No (Skip 1-2) Yes (omplete 1-2) sumitting clim on ehlf of the ptient or insured/suscrier.) 53. I herey certify tht the procedures s indicted y dte re in Ptient/Gurdin progress (for procedures signturetht require Dte 2. Months of Tretment 3. Replcement of Prosthesis?. Dte Prior Plcement (MM/DD/YY) multiple visits) or hve een completed. Remining 8. Nme, ddress, ity, Stte, Zip ode No Yes (omplete ) 37. I herey uthorize nd direct pyment of the dentl enefits otherwise pyle to me, directly to the elow nmed X dentist or dentl entity. 5. Tretment Resulting from Signed (Treting Dentist) Dte Occuptionl illness/injury uto ccident Other ccident 5. NPI 55. License Numer Suscrier signture Dte 6. Dte of ccident (MM/DD/YY) 7. uto ccident Stte Specilty ode ILLING DENTIST OR DENTL ENTITY (Leve lnk if dentist or dentl entity is not sumitting TRETING DENTIST ND TRETMENT LOTION INFORMTION 9. NPI 50. License Numer 51. SSN or TIN clim on ehlf of the ptient or insured/suscrier) 53. I herey certify tht the procedures s indicted y dte re in progress (for procedures tht require multiple visits) or hve een completed. 8. Nme, ddress, ity, Stte, Zip ode 52. Phone Numer ( ) dditionl 57. Phone Provider ID Numer ( ) dditionl Provider ID Signed (Treting Dentist) Dte 5. NPI 55. License Numer 56. ddress, ity, Stte, Zip ode 56. Provider Specilty ode 9. NPI 50. License Numer 51. SSN or TIN 52. Phone 52. dditionl 57. Phone 58. dditionl Numer ( ) Provider ID Numer ( ) Provider ID To Reorder cll J00 (Sme s D Dentl lim Form J01, J02, J03, J0) or go online t fold fold fold fold Dentl lim Forms & Envelopes 1200, 1201, 1202 Dentl lim Form Dentl lim Form fold fold X X 38. Plce of Tretment (e.g. 11=office; 22=O/P Hospitl) n X 56. ddress, ity, Stte, Zip ode 56. Provider X 2012 mericn Dentl ssocition J30D (Sme s D Dentl lim Form J30, J31, J32, J33, J3) X 2003ES 2006 mericn Dentl ssocition 2600, 2601, 2602 Dentl lims Forms Prt Numer Type Quntity Pper 1200 Lser Sheet 2500 Per rton 20# White, 8 1/2 x ontinuous 1-ply 2500 Per rton 20# White, 9 1/2 x ontinuous 2-ply 1000 Per rton 21# ron White 15# F White, 9 1/2 x Lser Sheet 2500 Per rton 20# White, 8 1/2 x ontinuous 1-ply 2500 Per rton 20# White, 9 1/2 x ontinuous 2-ply 1000 Per rton 21# ron White 15# F White, 9 1/2 x ES Envelope 500 Per rton -1/8x9 Window Envelope Self Sel Tylor Helthcre Forms tlog 6

7 Shred Medicl System ills SMSILL USMS2, USMS3 Shred Medicl System (SMS) lue ill Prt Numer Description Quntity Pper SMSILL ontinuous 2-ply # White 1# White F, 9 7/8 x 11 USMS2 ontinuous 2-ply # White 15# White F, 9 1/2 x 11 USMS3 ontinuous 3-ply # White 1# White F 15# White F, 9 1/2 x 11 Tylor Helthcre Forms tlog 7

8 Prescription Pper: Lser Sheets 8511RX 8555RX G Lser Prescription Pper Prt No. Description Quntity Size Security Fetures 8511RX 1-Up lue /2 x 11 Full hemicl Sensitive VOID oting, Lser Lock, Enhnced Lid Lines, nd Fluorescing Wtermrk 8555RX 2-Up lue /2 x 11 Full hemicl Sensitive VOID oting, Lser Lock, Enhnced Lid Lines, nd Fluorescing Wtermrk Up lue /2 x 11 Full hemicl Sensitive VOID oting, Lser Lock, Enhnced Lid Lines, nd Fluorescing Wtermrk 8525G -Up Green /2 x 11 Full hemicl Sensitive VOID oting, Lser Lock, Enhnced Lid Lines, nd Fluorescing Wtermrk recognized uthority in document security, Tylor Helthcre worked with issuers nd sttes for yers to provide more secure prescriptions. y employing new technology nd strictly controlled processes, Tylor Helthcre hs developed secure prescription progrms tht hve significntly reduced frudulent prescription ctivity. se in point: Tylor Helthcre worked with the stte of New York to reduce prescription frud. The stte reported the elimintion of more thn $68 million in frud within six months of deploying secure prescription progrm tht mndted use of Tylor Helthcre s prescriptions. When ongress pssed the ill requiring tmper-resistnt prescription pds for written Medicid outptient prescriptions, the enters for Medicre nd Medicid Services (MS) nd stte Medicid directors sought the counsel of Tylor ommunictions to understnd the nture of frud nd to lern how to crete truly tmperresistnt prescriptions. Tylor Helthcre Forms tlog 8

9 Prescription Pper: Direct Therml RXPSROLLLU-16, RXPSROLLLU- RXPSROLLW-16 RXPSROLLKY-16 RXPSROLLIN-16 Direct Therml Prescription Rolls Prt Numer Description Quntity ore Size Pper * Size RXPSROLLLU-16 lue 500 Per Roll 16 Rolls 1" Full hemicl Sensitive VOID oting, Lser Lock 1/ W x 5 1/2 H RXPSROLLLU- lue 500 Per Roll Rolls 1" Full hemicl Sensitive VOID oting, Lser Lock 1/ W x 5 1/2 H RXPSROLLIN-16 Indin RX 500 Per Roll 16 Rolls 1" Full hemicl Sensitive VOID oting, Lser Lock 5 1/2 W x 1/ H RXPSROLLKY-16 Kentucky RX 500 Per Roll 16 Rolls 1" Full hemicl Sensitive VOID oting, Lser Lock 5 1/2 W x 1/ H RXPSROLLW-16 Wshington RX 500 Per Roll 16 Rolls 1" Full hemicl Sensitive VOID oting, Lser Lock 1/ W x 5 1/2 H * Pper lso includes Enhnced Lid Lines nd Fluorescing Wtermrk Tylor Helthcre Forms tlog 9

10 Secure Prescription: Direct Therml Printer The Secure TSP800IIRX Prescription Printer is the only therml printer ville for the medicl industry with locking mechnism to deter unuthorized removl of prescription medi. The wide print width (for stte stndrd prescription pper), high print speed nd silent printing mke the TSP800IIRX the perfect Prescription Printer for ny medicl office, hospitl or clinic. enefits / Fetures Locking Pper hmer deters unuthorized form removl Disle Pper Feed function deters unuthorized dispensing Kensington Lock Slot provides dditionl security ginst theft when locking cle hrness is used (customer to supply cle) High Print Speed 37 prescriptions per minute t 203 Dots Per Inch (180mm/sec.) Wide pper formt.375 (10mm) with print width of up to llows printing of prescriptions, lels, forms nd reports Esy Drop-In & Print pper loding Direct therml printing elimintes the need for rions or ink crtridges Sensors for Ner End, Top of Form, over Open, nd Pper Out Jm-proof utomtic cutter with full or prtil cut: rted for up to 2 million cuts Includes externl power supply hrcol gry cse with smll footprint (7 x 8 ) Drivers ville include: Windows XP 32 it, Vist 32/6 it, Windows 7 32/6 it, Server /6 it, XP emedded, Linux, OPOS, JvPOS, M OS X ertifictions include: UL nd -UL, F, E mrking Works perfectly with Tylor Helthcre s Secure Therml Prescription Pper for mximum security rcode cpilities include ode 39/93/128, ITF, odr, PDF 17 Tylor Helthcre Forms tlog 10

11 Secure Prescription: Direct Therml Printer These printers re customer instllle. They do not include cles; order the pproprite cle. Stndrd Wrrnty One yer on lor, one yer on print hed nd cutter nd three yers on ll other prts. Printers must e returned to STR Micronics to otin service (depot). Secure Prescription Direct Therml Printer Model Prt Numer TSP800IIRX Prllel TSP800IIDRX Seril TSP800IIURX US TSP800IIERX Ethernet TSP800IIWRX Wifi Wrrnty Upgrdes Upgrded wrrnties extend lor, printhed nd cutter wrrnties to three yers. ll wrrnty upgrdes must e ordered t the sme time s the printer. Description Secure Prescription Direct Therml Printer ccessories & Wrrnties Prt Numer Verticl Wll Mount rcket Verticl Stnd Mount rcket onfigurtion Service for Verticl Mount 7GONFIG Prrellel le for Seril le (9 ) for US le (6 ) for Extend--Str 3 yer wrrnty upgrde Swp--Str 3 yer wrrnty upgrde Tylor Helthcre Forms tlog 11

12 Lser hecks: ottom Pnel US compnies lose more thn $900 illion to frud, with counterfeiting nd document frud responsile for two thirds of tht mount, ccording to the ssocition of ertified Frud Exminers. hecks re the pyment type most vulnerle to frud ttcks nd 77 percent of orgniztions ffected y pyments frud report tht checks were trgeted, the ssocition for Finncil Professionls sid in their 2015 FP Pyments Frud nd ontrol Survey. heck frud ccounts for the lrgest dollr mount of finncil loss ecuse of frud. hecks ccounted for 50 percent of 2 pyments in the US ecuse orgniztions usiness prtners nd hesitnt to switch to electronic pyments nd those prtners lso lk t shring nk informtion. To help mitigte check frud, finncil professionls cite controlled check stock not redily ville to frudsters nd the use of dul-time true wtermrks s the most effective fetures in preventing frud, ccording to the 2015 FP report. Tylor Helthcre is n industry leder in frud protection. Our thorough understnding of usiness documents nd prctices, myrid of security-relted ptents, rod technology nd engineering cpility nd n integrted suite of print nd digitl security mechnisms help helthcre orgniztions prevent frud in mny forms: counterfeiting, tmpering, identity theft nd emezzlement. 9703, 9903S, 992S 9711, 9911S, 9925S 9850, 9950S 9851S, 9951S 9852, 9952S 9913S hecks Prt No. Security Level olors Quntity 9703 Good Prismtic lue / Green / lue Good Prismtic lue / Red / lue Good Prismtic Red / lue / Red etter Solid Green etter Solid lue etter Solid Red S etter Prismtic lue / Green / lue S etter Prismtic lue / Red / lue S etter Prismtic Green / lue / Green S est Prismtic lue / Green / lue S est Prismtic lue / Red / lue S est Solid Green S est Solid lue S est Solid Red , 9911S, 9925S Tylor Helthcre Forms tlog 12

13 Lser hecks: Top & enter Pnel 9836, 9936S 9920S 9938S 9837, 9937S 9921S hecks Prt Numer Security Level olors Quntity heck Loction 9836 etter Solid lue 2000 Top Pnel 9837 etter Solid Green 2000 Top Pnel 9920S est Prismtic lue / Green / lue 2000 Top Pnel 9921S est Prismtic lue / Red / lue 2000 Top Pnel 9936S est Solid lue 2000 Top Pnel 9937S est Solid Green 2000 Top Pnel 9938S est Solid Red 2000 Top Pnel 9922S 9923S hecks Prt Numer Security Level olors Quntity heck Loction 9922S est Prismtic lue / Green / lue 2000 enter Pnel 9923S est Prismtic lue / Red / lue 2000 enter Pnel Forms re 8-1/2" x 11". ll designs hve full horizontl perfortion every 3-2/3". Tylor Helthcre Forms tlog 13

14 Lser hecks: 3-Up & -Up TS hecks Prt Numer Security Level olors Quntity heck Loction TS01 Good Prismtic Red / lue / Red Up with Stu Forms re 8-1/2" x 11". ll designs hve full horizontl perfortion every 3-2/3". hecks Prt Numer Security Level olors Quntity heck Loction 9709 Good Prismtic Red / lue / Red Up Forms re 8-1/2" x 11". ll designs hve full horizontl perfortion every 2-3/". Tylor Helthcre Forms tlog 1

15 Imge Sel hecks Imge Sel hecks with Windows Prt No. Size Quntity Fold Ink olor ontrol No. 8111Z 8 1/2 x Z Green nd lue Yes 8112Z 8 1/2 x Z Red nd Green Yes /2 x Green nd lue Yes 811Z 8 1/2 x Z lue Yes 812Z 8 1/2 x Z Green Yes Imge Sel hecks with See Through Pper Prt No. Size Quntity Fold Ink olor ontrol No. 801S0 8 1/2 x Green Yes 80S0 8 1/2 x Green Yes Tylor Helthcre Forms tlog 15

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