UB-04 Hospital Claim Form for Laser Printers (UB04LC)

Item #: 683689 | Model #: UB04LC

About this product

Laser forms are printed with red ink on 20-lb. paper.

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
  • Compatible with laser printers