| Enter the quantity of the forms
being requested. When ordering your 3 month supply, please be sure to indicate the total number of individual forms or envelopes needed in the Quantity column, not the number of boxes, cases or packages. |
Quantity |
HFS Form Number |
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215CF Drug Invoice, (Continuous Feed Format) |
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1409 Prior Approval Request |
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1443 Provider Invoice, (Single Sheet) |
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1443CF Provider Invoice, (Continuous Feed Format) |
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2209 Transportation Invoice, (Single Sheet) |
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2209CF Transportation Invoice, (Continuous Feed Format) |
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2210 Medical Equipment / Supplies Invoice, (Single Sheet) |
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2210CF Medical Equipment / Supplies Invoice, (Continuous Feed Format) |
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2211 Laboratory / Portable X-Ray Invoice, (Single Sheet) |
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2211CF Laboratory / Portable X-Ray Invoice, (Continuous Feed Format) |
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2212 Health Agency Invoice, (Single Sheet) |
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2212CF Health Agency Invoice, (Continuous Feed Format) |
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2360 Health Insurance Claim Form, (Single Sheet) |
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2360CF Health Insurance Claim Form, (Continuous Feed Format) |
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3797 Medicare Crossover Invoice (Single Sheet) |
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3797CF Medicare Crossover Invoice (Continuous Feed Format) |
|
HFS Envelope Number |
|
824MCR Medicare Crossover |
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1414 Special Approval |
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1415 Drug Invoice |
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1416 Adjustments |
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1444 Provider Invoice |
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2244 Transportation Invoice |
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2246 Health Agency Invoice |
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2247 Medical Equipment Supplies |
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2248 NIPS Special Invoice Handling |
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2294 Equip/Supplies Prior Approval |
|
2300 Prior Approval Request |
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Additional Forms Needed, Not Listed Above |
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