UB-04 Hospital Claim Form for Dot-Matrix Printers, 2-Part

Item: 683687 Model: UB042

Easily file a medical claim with a patient's insurance carrier
File a hard copy of each claim with patient records in case you need to resubmit a claim
2-Part forms

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Easily file a medical claim with a patient's insurance carrier
File a hard copy of each claim with patient records in case you need to resubmit a claim
2-Part forms
Continuous forms, compatible with Dot-Matrix printers