Revised CMS 1500 (08/05) UB04 (Revised UB92) The CMS 1500 and UB04 claim form revisions are necessary to accomodate National Provider Identifier (NPI) codes for healthcare providers.

Wilmer is one of the industry's largest trade manufacturers of healthcare claim forms including the CMS/HCFA-1500, ADA, and UB92 claim forms. Wilmer will not accept returns of HCFA Claim Forms (old version, 12/90) after January 5, 2007; UB92 after March 1, 2007.

Wilmer maintains inventories of these products in four locations to help minimize freight costs. The warehouse locations for these products include:

Atlanta, GA
Edison, NJ
Coldwater, OH
Visalia, CA

These products are offered in a wide variety of versions and sizes (8-1/2" x 11", 9-1/2" x 11" and 9-1/2" x 14"); OCR red ink color.

• 1-part laser cut-sheet
• 2-part carbonless unit set
• 1-part continuous
• 2-part carbonless continuous
• 3-part carbonless continuous
• 4-part carbonless continuous