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Tops UB-04 Hospital Claim Form

Tops Products at

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

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Product Number: TOP59770R
Nordisco Price
$143.94 CT

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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


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

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