ComplyRight UB-04 Hospital Claim Form, 500 Forms/Pack (UB04LC5)
$30.19
1
Highlights
View all details
- Designed for hospitals to file a medical claim with the patient's insurance carrier
- One-part health insurance forms
- Printed with OCR dropout red ink on white paper
MADE IN AMERICA
ComplyRight UB-04 Hospital Claim Form, 500 Forms/Pack (UB04LC5)
Item #: 24614845Model #: UB04LC5
No reviews yet
$30.19
Free Returns
Online. In store. Always free.
Learn More
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Over 30
Add to list
Consider this similar product
About this product
Complete billing tasks with these TFP UB-04 one-part hospital claim forms
Ensure proper processing of medical procedures and patient care with these hospital claim forms. The 20-pound bond paper offers added durability and is easy to load in office printers, while the one-part format creates a crisp, high-quality master copy. Each of these TFP UB-04 hospital claim forms features preprinted sections for services, codes, and rates, along with each patient's personal information for accurate reporting.
- Designed for hospitals to file a medical claim with the patient's insurance carrier
- One-part health insurance forms
- Printed with OCR dropout red ink on white paper
- Developed in conjunction with all the governing agencies
- Comes in laser-cut sheet format
Frequently bought together
Page 1 of 3
Price is $42.49
Unit of measure 100/Pack
Free Next-Day eligible by tomorrow
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Over 30
Add to list
Price is $13.09
Next-Day Delivery by tomorrow
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Over 30
Add to list
Price is $55.99
Unit of measure 500/Carton Price per unit $0.11/Cup
Free Next-Day eligible by tomorrow
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Over 30
Add to list
Price is $48.09
Unit of measure 500/Pack
Free delivery by Wed, Jul 01
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Over 30
Add to list
Price is $85.89
Unit of measure 1000/Carton
Free Next-Day eligible by tomorrow
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Over 30
Add to list
Compare similar items
| Attributes | ComplyRight UB-04 Hospital Claim Form, 500 Forms/Pack (UB04LC5) | TFP UB-04 CMS-1450 Health Insurance Claims, 2500/Carton (UB04LC) | ComplyRight CMS-1500 Health Insurance Claims, 2500/Pack (CMS12LC) | ComplyRight CMS-1500 Health Insurance Claim Forms (02/12), 8-1/2" x 11", Box of 1,000 (CMS12LC1) | ComplyRight 2024 ADA Dental Claim Forms, 2,500 Forms/Pack (20241) |
|---|---|---|---|---|---|
Your product ComplyRight UB-04 Hospital Claim Form, 500 Forms/Pack (UB04LC5) Price is $30.19 |  Price is $93.89 |  Price is $91.89 |  Price is $85.89 |  Price is $133.69 | |
| Reviews | |||||
| Delivery Information | Delivery by Tue, Jul 07 | Free delivery by Wed, Jul 01 | Free delivery by Wed, Jul 01 | Free Next-Day eligible by tomorrow | Free delivery by Wed, Jul 01 |
| Available in my store | No | No | No | No | No |
| Length in Inches | 11 | Data not available | 11 | 11 | 11 |
| Width in Inches | 8.5 | Data not available | 8.5 | 8.5 | 8.5 |
| Medical Form Pack Size | 500 | 2500 | 2500 | 1000 | 2500 |
| Medical Form Type | Health Insurance Claims | Health Insurance Claims | Health Insurance Claims | Health Insurance Claims | Dental Claims |
| Print Type | Laser | Laser | Laser | Laser | Laser |
| Acid Free | Acid Free | Data not available | Acid Free | Acid Free | Acid Free |
| Add To Cart | Add To Cart | Add To Cart | Add To Cart |
Featured Products
Page 1 of 3
Price is $49.59
Unit of measure 250/Box
Free delivery by Tue, Jun 30
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Over 30
Add to list
Price is $81.69
Unit of measure 500/Box
Free delivery by Tue, Jun 30
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Over 30
Add to list
Price is $17.69
Delivery by Mon, Jul 06
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Over 30
Add to list
Price is $17.39
Unit of measure 100/Pack
Delivery by Tue, Jun 30
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Over 30
Add to list
Price is $17.95
Delivery by Mon, Jul 06
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Over 30
Add to list
