order layout - Bibbero Systems, Inc.

Toll Free:
Fax:
E-mail:
Web:
* ORDER LAYOUT *
Meets Current
Medicaid Security Requirements
Clinical Records Specialists Since 1953
1300 No. McDowell Blvd.
Petaluma, CA 94954-1180
(800) 242-2376
(800) 242-9330
[email protected]
www.bibbero.com
ALTER-RESISTANT
PRESCRIPTION BLANKS - STANDARD SIZE & FULL SHEET
Standard Size Security Features: Tamper Resistant Green or Blue Background Detects
Erasures, Void Pantograph, Security Paper w/Invisible Ultra-Violet Fibers & Protection
Against Bleach or Solvent Washing, Security Features Listed on Back.
The background pattern appears on both sides of the first part of the prescription blank and makes
any erasure immediately apparent. On the two-part format, the second part has screened “VOID”
copy printed across it. These alter-resistant blanks can be faxed or copied for your files. Standard
size available in a horizontal (Style H) or vertical (Style V) format. Submit your personalized
information, including your state license and/or DEA number, if required by your state. An AlterResistant Blank Sheet (8½” x 11”) is available, without personalization, for laser printers.
General Practice
135 So. Elm Street
San Francisco, California 94117
Telephone: (415) 555-1212
FOR
DATE
ADDRESS
1-Part (Pads of 100)
SKU: 25-8293
Green
Blue
Minimum Order: 10 Pads
(1,000 Rx Blanks)
Quantity:
Submit a sample layout. Otherwise,
10 Pads
we will advise you of information
20 Pads
required by your state.
40 Pads
60 Pads
80 Pads
THOMAS A. SCOTT, M.D.
Style V
THOMAS A. SCOTT, M.D.
Style H
General Practice
135 So. Elm St.
Sacramento, Ca. 94107
Telephone: (916) 344-5550
FOR
DATE
ADDRESS
2-Part Sets (Pads of 50)
Second Part Blank
SKU: 25-8293-02
Second Part Printed Same as First
SKU: 25-8293-02S
Minimum Order: 20 Pads
(1,000 Rx Blanks)
REFILL
CAL. LIC. # G0053
DEA# BS00267322
TIMES
CAL. LIC. #G099914
DEA #AK08888888
20 Pads
60 Pads
120 Pads
40 Pads
80 Pads
Style:
H - Horizontal V - Vertical
REFILL
, M.D.
Thomas A. Scott, M.D.
Bibbero Systems, an InHealth Company
TIMES
To Reorder: Call 800-242-2376
##### Formname (00.00.14)
Thomas A. Scott, M.D.
#25-8293 H
(Size 5 1⁄2” x 4 1⁄4”) Base Copy White Safety Paper with Green or Blue Background- Imprint Information Black
2-Part Forms: First Part Green w/ Second Part Pink w/screen “VOID” printed.
LASER FORMAT ALSO AVAILABLE
Alter-Resistant Blank Sheet (8½” x 11”)
SKU: 25-RXLASER (Green)
Minimum Order: 500
Alter-Resistant Blank Sheet (8½” x 11”)
SKU: 25-RXLASER/BL (Blue)
Minimum Order: 500
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Please complete section below * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
Practice Name
Physician Name
Specialty
(Not required on printed Rx. Print Specialty on Rx?
E-Mail
Yes
No)
(Print E-Mail on Rx?
Yes
No)
Address
City
State
Zip
Phone
DEA #
Fax
(Not required on printed Rx. Print Fax # on Rx?
DEA#
Physician Signature
(as above) or
(or authorized person)
Preprint DEA#
License #
LIC.#
(as above) or
Date
Yes
No)
Preprint LIC.#
Toll Free:
Fax:
E-mail:
Web:
Clinical Records Specialists Since 1953
(800) 242-2376
(800) 242-9330
[email protected]
www.bibbero.com
1300 No. McDowell Blvd.
Petaluma, CA 94954-1180
Pricing for Alter-Resistant Prescription Blanks & Blank Sheets
STANDARD SIZE – Personalized
Pricing for one- or two-part personalized standard size Prescription Blanks, based on the following standard features:
l Base copy of white safety paper with light green or blue background (1-Part) or white safety paper
with green background and pink clean carbon (2-Part).
l Erase resistant.
l VOID Pantograph.
l Anti-forgery protection against bleach or solvent washing.
l Security features are listed on back.
l Personalized copy printed in black ink.
l Form size is 5½” x 4¼”.
l Pads of 100 for 1-Part and Pads of 50 for 2-Part Prescription Blanks (1,000 Rx Blanks).
Price per 1000 Rx Blanks
10
20
40
60
80
SKU 25-8293
1-Part (Pads of 100) 55.20
49.99
41.80
36.80
35.60
Price per Pad
20
40
60
80
120
SKU 25-8293-02 2-Part (Pads of 50)
8.45
7.20
6.20
4.60
3.80
SKU 25-8293-02S 2-Part (Pads of 50)
8.45
7.20
6.20
4.60
3.80
Required personalization information needs to be submitted with order. Add $25.00 - $35.00 art fee for
new Rxs (depending on complexity). After receipt of order and layout information, allow 1-3 working days
for preparation of proof copy. After approval of proof, allow 10-15 working days for printing, plus additional
time for transit.
Alter-Resistant BLANK SHEETS (for Laser Printers)
Pricing for 1-Part Alter-Resistant Blank Full Sheet, based on the following standard features:
l White safety paper with light green or blue background.
l Erase resistant.
l VOID Pantograph.
l Anti-forgery protection against bleach or solvent washing.
l Security features are listed on back.
l Form size is 8½” x 11”.
l No personalization.
Price per 100 Sheets
500
1,000
2,500
5,000
SKU 25-RXLASER
6.306.205.755.30
SKU 25-RXLASER/BL 6.306.205.755.30
Shipping costs are additional charges that will be added to final invoice.
Shipping Address (if different than imprinted information on reverse).
Street Address:
City:
State:
Zip:
Bibbero Systems, an InHealth Company
To Reorder: Call 800-242-2376
AF0692 OF (06.18.15)