Prescription Forms

Sold in packs of 500

Bulk packed
Size 8 ½" x 11 ".
Stock 60# Laser/Offset.

6 security features
Warning: Absence of the Following Security Features May Indicate Alteration.
1. Tamper resistant background ink shows attempts to alter script.
2. Penetrating ink is used to prevent chemical “lifting” of information.
3. High security watermark on back side, which cannot be copied and can only be seen at 45o angle, is coin-reactive and changes color when scratched with a coin.
4. Each sheet is sequentially numbered for record keeping. (Not applicable with Laser sheets)
5. Security pantograph prints “VOID” on front when duplicated.
6. Thermochromatic ink on the front side. The word “SECURE” will fade away and reappear.
• Security Features on this document exceed CMS guidelines

1 Part Security Pad
(4up1P-Blue or Green)
100 Sheets per Pad
Size 4 ¼” x 5 ½”

6 security features
Warning: Absence of the Following Security Features May Indicate Alteration.
1. Tamper resistant background ink shows attempts to alter script.
2. Penetrating ink is used to prevent chemical “lifting” of information.
3. High security watermark on back side, which cannot be copied and can only be seen at 45o angle, is coin-reactive and changes color when scratched with a coin.
4. Each sheet is sequentially numbered for record keeping. (Not applicable with Laser sheets)
5. Security pantograph prints “VOID” on front when duplicated.
6. Thermochromatic ink on the front side. The word “SECURE” will fade away and reappear.
• Security Features on this document exceed CMS guidelines

2 Part Security Pad
(4up2P-Blue or Green)
100 Sheets per Pad
Size 4 ¼” x 5 ½”
Each pad contains 100 sheets
Second Copy is unprinted yellow sheet with no security features.

6 security features
Warning: Absence of the Following Security Features May Indicate Alteration.
1. Tamper resistant background ink shows attempts to alter script.
2. Penetrating ink is used to prevent chemical “lifting” of information.
3. High security watermark on back side, which cannot be copied and can only be seen at 45o angle, is coin-reactive and changes color when scratched with a coin.
4. Each sheet is sequentially numbered for record keeping. (Not applicable with Laser sheets)
5. Security pantograph prints “VOID” on front when duplicated.
6. Thermochromatic ink on the front side. The word “SECURE” will fade away and reappear.
• Security Features on this document exceed CMS guidelines

1 Part Security Pad
CMS Prescription Pads
Large - Size 5 ½” x 8 ½”
Blue or Green

6 security features
Warning: Absence of the Following Security Features May Indicate Alteration.
1. Tamper resistant background ink shows attempts to alter script.
2. Penetrating ink is used to prevent chemical “lifting” of information.
3. High security watermark on back side, which cannot be copied and can only be seen at 45o angle, is coin-reactive and changes color when scratched with a coin.
4. Each sheet is sequentially numbered for record keeping. (Not applicable with Laser sheets)
5. Security pantograph prints “VOID” on front when duplicated.
6. Thermochromatic ink on the front side. The word “SECURE” will fade away and reappear.
• Security Features on this document exceed CMS guidelines