Call Toll Free 1-800-621-1891
 
 
 
 
FREE SHIPPING on Orders Over $50
 
Item Added to Cart
 
 
Share Print Page Recently Viewed

You have not viewed any products recently.

 
 
1014265165.jpg Enlarge View
1014265165.jpg
Alternative Views
  • There are no alternate images available for this product.
 
  • There are no alternate images available for this product.

Tops UB-04 Hospital Claim Form

Tops Products at Nordisco.com

Tops UB-04 Hospital Claim Form - 1 Part - 11" x 8.5" Form Size - 2500 / Carton

Most orders over $50 ship free - see details
 
Product Number: TOP59770R
Nordisco Price
$143.94 CT

Enter full name. We'll ask for delivery information at checkout.

 
 

UB-04 continuous forms are designed for hospitals 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.

General Information

Manufacturer: Tops Products
Manufacturer Part Number: 59770R
Brand Name: Tops
Product Model: UB-04
Product Name: UB-04 Hospital Claim Form
Packaged Quantity: 2500 / Carton
Product Type: Claim Form

Product Information

Media Quantity: (1 Form Per Sheet)
Form Size: 11" Length x 8.50" Width
Number of Parts: 1 Part
Print: Front Side Form With Red Ink
Print Technology: Dot Matrix

Physical Characteristics

Color: White

Miscellaneous

Recycled: No
Recycled Content: 0%
Post-consumer-waste%: 0%
Assembly Required: No

Related Items

Breakroom and Janitorial
 
Setup an Account
 
 
Office Supplies
Furniture
Ink & Toner
Paper
Janitorial Supplies
School
Shop Green
Technology
Coffee & Breakroom