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UB-04 Hospital Claim Form for Dot-Matrix Printers

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

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Item 683688 Model UB041	UB-04 Hospital Claim Form for Dot-Matrix Printers, 1-Part 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 1-Part forms	Expected Delivery3 - 5 Business Days	Price: *$52.99* 2,500/Box	Details	Qty. Add to Favorites
Item 683688 Model UB041			Price: *$52.99* 2,500/Box	Details	Qty. Add to Favorites
Item 683687 Model UB042	UB-04 Hospital Claim Form for Dot-Matrix Printers, 2-Part 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	Expected Delivery3 - 5 Business Days	Price: *$57.99* 1,000/Box	Details	Qty. Add to Favorites
Item 683687 Model UB042			Price: *$57.99* 1,000/Box	Details	Qty. Add to Favorites
Item 683686 Model UB043	UB-04 Hospital Claim Form for Dot-Matrix Printers, 3-Part 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 3-Part forms	Expected Delivery3 - 5 Business Days	Price: *$99.99* 1,000/Box	Details	Qty. Add to Favorites
Item 683686 Model UB043			Price: *$99.99* 1,000/Box	Details	Qty. Add to Favorites
Item 683685 Model UB044	UB-04 Hospital Claim Form for Dot-Matrix Printers, 4-Part 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 4-Part forms	Expected Delivery3 - 5 Business Days	Price: *$68.99* 500/Box	Details	Qty. Add to Favorites
Item 683685 Model UB044			Price: *$68.99* 500/Box	Details	Qty. Add to Favorites
Images Off	sort by Name	sort by Delivery	sort by Price		Add to Cart

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