Tops UB-04 Hospital Claim Form - 2500 per carton TOP59770R + Click to enlarge

Tops UB-04 Hospital Claim Form - 2500 per carton

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

Reg. Price $186.17
Our Price $106.02
Per Carton

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

SKU
TOP59770R
Manufacturer
Tops Products
Manufacturer Part Number
59770R
Brand Name
Tops
Product Model
UB-04
Packaged Quantity
2500 / Pack
Product Type
Claim Form
Color
White
Form Size
11" Length x 8.50" Width
Number of Parts
1 Part
Print
Front Side Form With Red Ink
Print Technology
Dot Matrix
Recycled
No
Green Compliant
Yes
Green Compliance Certificate/Authority
SFI