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Tops UB-04 Continuous Billing Form TOP59772R + Click to enlarge

Tops UB-04 Continuous Billing Form

2 Part - Carbonless - 11" x 9.50" Form Size - 1000 / Carton

Reg. Price: $151.67

Our Price: $100.34

Per Carton
QTY.
In Stock and Ready to Ship!

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). Continuous forms are printed on 20 lb. bond paper.

SKU
TOP59772R
Manufacturer
Tops Products
Manufacturer Part Number
59772R
Brand Name
Tops
Product Model
UB-04
Packaged Quantity
1000 / Pack
Product Type
Claim Form
Color
White
Form Size
11" Length x 9.50" Width
Number of Parts
2 Part
Copy Type
Carbonless
Print
Front Side Form With Black Ink
Print Technology
Laser
Features
Perforated
Weight (Approximate)
19.00 lb
Certifications & Standards

Medicare and Medicaid Services

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