Tops UB-04 Hospital Claim Form

1 Part - 11" x 8.50" Form Size - 2500 / Carton

Product Number: TOP59870R

In Stock

$106.96/ 2500/CT

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	Estimated delivery: Fri 3/26 Thu 3/25 FREE Shipping - see details REMINDER: NO SALES TAX (excludes WI and CA) Request volume price quote

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	Shipped by truck directly from the factory For manufacturer direct, estimated expected delivery Mon 4/5 Need a larger quantity? Manufacturer direct pricing is for you. Shipping from the manufacturer lets us save on shipping and operational costs, thereby saving you money. It may take a bit longer to arrive, but it allows us to offer you the best prices on the internet. FREE Shipping - see details Reminder - No Sales tax (excludes Wisconsin)

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UB-04 laser-cut forms are designed for medical offices to file a claim with the patient's insurance company. The Health Care Finance Administration format ensures accuracy in reporting all necessary information. Forms meet the requirements of the Centers for Medicare and Medicaid Services (CMS). Forms are printed on 20 lb. bond paper.

Product Specs

Product Information

Post-Consumer Recycled Content Percent	0 %
Pre-Consumer Recycled Content Percent	0 %
Total Recycled Content Percent	0 %
Paper Color(s)	Red White
Printer Compatibility	Laser
Format	Loose Form
Layout	One Form per Sheet
Paper Stock	20-lb.
Print and Ruling Color(s)	Red
Form Size (W x H)	8 1/2 in x 11 in
Global Product Type	Forms-Insurance Claim
Product Type	Claim Form
Format	Loose Form
Manufacturer Part Number	59870R
Manufacturer Website Address	www.tops-products.com
Color	White
Certifications & Standards	American Medical Association
Media Quantity	(1 Form Per Sheet)
Product Name	UB-04 Hospital Claim Form
Print Technology	Laser
Brand Name	Tops
Country of Origin	United States
Layout	One Form per Sheet
Print	Front Side Form With Red Ink
Recycled	No
Recycled Content	0%
Post-consumer-waste%	0%
Assembly Required	No
Form Size	11" Length x 8.50" Width
Sheet Size	8 1/2 x 11
Number of Parts	1 Part