Office Forms Medical History Questionnaire A key component for proper CMS documentation. Available in English or Spanish, 2-sided forms printed "head-to head" or "head-to-toe". Click Here For Sample   Regular Price PEN Member Price 50 Forms (Spanish Only) $15.00 $12.00 100 Forms (English/Spanish) $20.00 $16.50 200 Forms (English/Spanish) $32.00 $27.50 500 Forms (English/Spanish) $69.00 $60.50 1000 Forms (English/Spanish) $121.00 $110.00 Examination Form Includes clear reference to all 14 elements of an eye exam that Medicare recognizes. The form allows auditors to readily confirm that your documentation is thorough and compliant. At the conclusion of the exam, simply count the number of elements documented to determine the level of examination performed. Click Here For Sample   Regular Price PEN Member Price 100 Forms $16.50 $14.00 200 Forms (English/Spanish) $24.50 $21.00 500 Forms (English/Spanish) $53.00 $47.00 1000 Forms (English/Spanish) $88.00 $80.00 Examination: Supplementary Tests Form Medicare requires detailed documentation and interpretation for Extended Ophthalmoscopy, Fundus Photography, Visual Fields, Gonioscopy, Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI), and Pachymetry. These forms are a quick and easy way to comply with CMS regulations when performing these tests. At the conclusion of the exam, simply count the number of elements documented to determine the level of examination performed. Click Here For Sample   Regular Price PEN Member Price 50 Forms $15.00 $12.00 100 Forms $20.00 $16.50 200 Forms $32.00 $27.50 500 Forms $69.00 $60.50 Customized Medicare Fee Schedule Customized according to your practice's specific Medicare region and whether you are a participating ("par") or non-participating ("non-par") provider with Medicare. Includes one schedule for services and another for materials. Procedure codes for services and materials are separated into categories (office medical exam, trifocal lenses, etc.). A description of each procedure code follows the CPT code itself. Updated annually and specific to optometry.   Regular Price PEN Member Price   $28.00 $18.00 Billing & Coding Compliance Kit All the tools needed for billing and complying with medicare requirements in one handy kit! Includes: Medical History Questionnaire (100 Forms) Examination Form (100 Forms) Examination: Supplementary Form (50 Forms) CMS-1500 Claim Form, 1-Part (50 Forms) Signature-on-File Labels (60 Labels) Evaluation & Management Worksheet Customized Medicare Fee Schedule Common Diagnosis Card Physician Quality Reporting Initiative (PQRI) Quick Reference Card   Regular Price PEN Member Price   $120.00 $85.00 Optometric Superbill Reviewed and updated annually, the Superbill lists codes specific to optometry. Available in both 1-part padded and 3-part NCR formats, includes personalized imprinting and sequential numbering at no additional charge. Click Here For Sample 1-Part Padded Forms Regular Price PEN Member Price 250 Forms $151.50 $127.50 500 Forms $168.00 $145.00 1000 Forms $242.00 $211.00 2000 Forms $385.50 $343.00 5000 Forms $748.00 $677.50   3-Part NCR Forms Regular Price PEN Member Price 250 Forms $199.00 $167.50 500 Forms $220.50 $190.50 1000 Forms $317.50 $277.00 2000 Forms $506.00 $450.00 5000 Forms $982.00 $889.00 Rx Pads Choose from five formats: Custom Rx Pad No Drugs Listed Glaucoma Drugs Anti-Infective Drugs Anti-Inflammatory/Anti-Allergy Drugs Select from two different printing styles: 50 sheet pad, each format printed on a different color for quick recognition (carbonless copies not available with colored paper) 25 sets of 2-part NCR forms printed on white paper with yellow carbonless copies (colored paper not available with NCR) Includes common Rx abbreviations that you simply circle, personalized imprinting and a quick reference card of abbreviations. Click Here For Sample Pads Click Here For the List of Drugs You Can Choose From For Custom Rx Pads   Regular Price PEN Member Price 4 Pads $55.00 $45.50 8 Pads $66.00 $54.50 16 Pads $85.00 $71.00 32 Pads $149.00 $126.00 64 Pads $286.00 $238.00 Pricing breakdown is per type of Rx pad. Evaluation & Management Worksheet Determining the mostappropriate E/M service code (99000 series) is easy with this "coding calculator". It incorporates a simplified, four-step process that is clear and straightforward. 8½" X 11" laminated card. Click Here For Sample   Regular Price PEN Member Price 1 Card $10.50 $8.50 2-9 Cards $8.50 $6.75 10 or More $6.50 $5.25 Lifetime Signature-on-File Labels Legally submit patients' claims without having them sign each individual claim form. Simply attach the signed label to patient's chart and stamp "signature on file" on his/her insurance claim forms. Contains approved Medicare language. Designed to be used for any insurance plan. Available in English and Spanish. Click Here For Sample   Regular Price PEN Member Price 60 Labels $25.00 $21.00 300 Labels $41.00 $36.00 600 Labels $73.00 $65.00 CMS 1500 Claim Forms Health Insurance Claim Form. 2-part NCR continuous-feed or 1-part laser. 1 Part Laser Regular Price PEN Member Price 100 Forms $12.00 $11.00 500 Forms $34.00 $31.00 1000 Forms $56.00 $52.50   2-Part NCR Regular Price PEN Member Price 100 Forms $16.50 $14.50 500 Forms $55.00 $51.50 1000 Forms $86.00 $78.00 Duty-to-Inform Labels Informing every eyewear patient of the proper use and the safety issues related to opthalmic lens materials is very important. Available in English and Spanish. Click Here For Sample   Regular Price PEN Member Price 100 Labels $31.00 $26.50 250 Labels $38.50 $34.00 1000 Labels $73.00 $65.00 HIPAA Acknowledgement of Receipt Labels Under HIPAA regulations, you must make a "good faith effort" to obtain written acknowledgement that each patient has received your Notice of Privacy Practices. Comply with HIPAA and save space in the patient's chart at the same time. Click Here For Sample   Regular Price PEN Member Price 60 Labels $25.00 $21.00 300 Labels $41.00 $36.00 600 Labels $73.00 $65.00 Common Diagnosis Codes Keep the most commonly used diagnosis codes at your fingertips. 2-sided, laminated card includes a helpful key of specific procedure codes and diagnosis codes that are payable together. Click Here For Sample   Regular Price Per Card PEN Member Price Per Card 1 Card $14.00 $11.25 2-9 Cards $11.25 $9.00 10 or More $8.75 $7.00 Treatment Sheets Written instructions increase patient's treatment compliance & success! Much more than the typical, patient take-home, fact-sheet, Treatment Sheets are designed to save you time and to give patients take-home information specific to their situation including: General information describing the condition. Treatment options & instructions with check-boxes. Space for listing medication and follow-up visit information. Pads are 50 sheets each. Topics include: Computer Vision Syndrome, Corneal Abrasion, Dry Eye, Eye Drops & Ointment, Eyelid Problems, Keratoconus. Click Here For Sample   Regular Price PEN Member Price 1 Pad $15.00 $12.00 2 Pads $20.00 $16.50 4 Pads $32.00 $27.50 6 Pads $44.50 $39.00 10 Pads $69.00 $60.50 Medicare Quick Reference Card This laminated, 2-sided card keeps the commonly used codes, modifiers and Medicare rules at your fingertips. Click Here For Sample   Regular Price PEN Member Price 1 Card $10.50 $8.50 2-9 Cards $8.50 $6.75 10 or More $6.50 $5.25 Informed Consent Aid your patients and protect your practice at the same time! Doctors agree they should use an informed consent, but most don’t. Now, PEN has made it easy. This form can be used for any procedure and is conveniently packaged in 50-sheet pads. Click Here For Sample   Regular Price PEN Member Price 1 Pad $15.00 $12.00 2 Pads $20.00 $16.50 4 Pads $32.00 $27.50 6 Pads $44.50 $39.00 Physician Quality Reporting Initiative (PQRI) Quick Reference Card In 2006, CMS created the Physician Quality Reporting Initiative (PQRI) which allows eligible professionals to participate in a voluntary quality reporting program. Those who successfully report a designated set of quality measures, using the quality-data codes on claims, will be eligible to earn a bonus payment (subject to a cap) of 1.5% of total allowed charges for covered Medicare physician fee schedule services. This laminated, two-sided card keeps details of the measures that apply to optometrists at your fingertips for quick reference. Click Here For Sample   Regular Price Per Card PEN Member Price Per Card 1 Card $14.00 $11.25 2-9 Cards $11.25 $9.00 10 or More $8.75 $7.00 Click here for Ordering Information. Click here for PEN’s Order Form. 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