Cart Summary
Cart   
  Checkout
Back to: Accounting / Forms Health Care Forms
printPrint this Page
UB-04 Hospital Claim Form for Dot-Matrix Printers
UB-04 Hospital Claim Form for Dot-Matrix Printers

UB-04 Hospital Claim Form for Dot-Matrix Printers

Price:
As low as
$57.99
2,500/Box
57.99Easily file a medical claim with a patient's insurance carrierFile a hard copy of each claim with patient records in case you need to resubmit a claimAvailable in one, two, three and four-part formsUB-04 Hospital Claim Form for Dot-Matrix Printershttp://s7d5.scene7.com/is/image/Staples/s0200809_sc7?$std$http://s7d5.scene7.com/is/image/Staples/s0200809_sc7?$thb$http://s7d5.scene7.com/is/image/Staples/s0200809/UB-04-Hospital-Claim-Form-for-Dot-Matrix-Printers/product_SS1034853UB-04 Hospital Claim Form for Dot-Matrix Printers0.00 57.99Easily file a medical claim with a patient's insurance carrierFile a hard copy of each claim with patient records in case you need to resubmit a claim1-Part formsUB-04 Hospital Claim Form for Dot-Matrix Printers, 1-Parthttp://s7d5.scene7.com/is/image/Staples/s0200809_sc7?$std$http://s7d5.scene7.com/is/image/Staples/s0200809_sc7?$thb$http://s7d5.scene7.com/is/image/Staples/s0200809/UB-04-Hospital-Claim-Form-for-Dot-Matrix-Printers-1-Part/product_683688UB-04 Hospital Claim Form for Dot-Matrix Printers, 1-Part0.00 62.99Easily file a medical claim with a patient's insurance carrierFile a hard copy of each claim with patient records in case you need to resubmit a claim2-Part formsUB-04 Hospital Claim Form for Dot-Matrix Printers, 2-Parthttp://s7d5.scene7.com/is/image/Staples/s0200809_sc7?$std$http://s7d5.scene7.com/is/image/Staples/s0200809_sc7?$thb$http://s7d5.scene7.com/is/image/Staples/s0200809/UB-04-Hospital-Claim-Form-for-Dot-Matrix-Printers-2-Part/product_683687UB-04 Hospital Claim Form for Dot-Matrix Printers, 2-Part0.00 109.99Easily file a medical claim with a patient's insurance carrierFile a hard copy of each claim with patient records in case you need to resubmit a claim3-Part formsUB-04 Hospital Claim Form for Dot-Matrix Printers, 3-Parthttp://s7d5.scene7.com/is/image/Staples/s0200809_sc7?$std$http://s7d5.scene7.com/is/image/Staples/s0200809_sc7?$thb$http://s7d5.scene7.com/is/image/Staples/s0200809/UB-04-Hospital-Claim-Form-for-Dot-Matrix-Printers-3-Part/product_683686UB-04 Hospital Claim Form for Dot-Matrix Printers, 3-Part0.00 72.99Easily file a medical claim with a patient's insurance carrierFile a hard copy of each claim with patient records in case you need to resubmit a claim4-Part formsUB-04 Hospital Claim Form for Dot-Matrix Printers, 4-Parthttp://s7d5.scene7.com/is/image/Staples/s0200809_sc7?$std$http://s7d5.scene7.com/is/image/Staples/s0200809_sc7?$thb$http://s7d5.scene7.com/is/image/Staples/s0200809/UB-04-Hospital-Claim-Form-for-Dot-Matrix-Printers-4-Part/product_683685UB-04 Hospital Claim Form for Dot-Matrix Printers, 4-Part0.00

Printed with red ink on white carbonless 20-lb. paper for trouble-free use in your printer.

The UB-04 contains a number of improvements and enhancements that include better alignment with the electronic HIPAA ASC X12N 837-Institutional Transaction Standard. The New UB-04 paper billing form will be able to accommodate the reporting of the National Provider Identifier (NPI) Number. The NPI will be a single provider identifier, replacing the different provider identifiers healthcare systems currently use for each health plan with which you do business. The NPI Identifier, which implements a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), must be used by all HIPAA covered entities, which are health plans, healthcare clearinghouses, and healthcare providers.

  • 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
  • Available in one, two, three and four-part forms
  • Continuous forms, compatible with Dot-Matrix printers

This Web site is intended for use by US residents only.See International Sites.

See our delivery policy for full details.

Copyright 2011, Staples, Inc., All Rights Reserved.

Questions? Call 1-800-STAPLES (1-800-782-7537) or email us at http://www.staples.com/emailus.

Site Map | RSS Feed