ComplyRight UB-04 Hospital Claim Form, 500 Forms/Pack (UB04LC5)
$28.59
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
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
Final price is $28.59
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
Consider this similar product
No reviews yet
Price is $77.79
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
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
Price is $22.49
Unit of measure 50/Box
Delivery by Mon, Jun 23
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
Price is $71.79
Unit of measure 150/Box Price per unit $0.48/Folder
Free delivery by Mon, Jun 23
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
Price is $24.59
Unit of measure 18/Pack Price per unit $0.01/Post-it® Note
Delivery by Mon, Jun 23
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
Price is $14.69
Unit of measure 24/Pack
Delivery by Mon, Jun 23
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
Price is $15.59
Delivery by Thu, Jun 26
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
Price is $26.09
Unit of measure 6/Pack Price per unit $4.35/Envelope
Delivery by Thu, Jun 26
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
Price is $40.09
Free delivery by Mon, Jun 23
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
Price is $321.69
Unit of measure 24/Pack
Free delivery by Thu, Jun 26
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
Price is $7.99
Delivery by Mon, Jun 23
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
Price is $337.79
Unit of measure 24/Pack Price per unit $14.08/Expanding File
Free delivery by Thu, Jun 26
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
Price is $44.19
Unit of measure 10/Box Price per unit $4.42/Expanding Wallet
Free delivery by Mon, Jun 23
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
Price is $46.49
Unit of measure 10/Box Price per unit $4.65/File Pocket
Free delivery by Mon, Jun 23
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
Price is $14.39
Delivery by Mon, Jun 23
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
Price is $24.69
Delivery by Thu, Jun 26
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
Price is $26.59
Unit of measure 25/Pack
Delivery by Mon, Jun 23
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
Price is $10.49
Delivery by Mon, Jun 23
1-hr pickup
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
Price is $9.69
Unit of measure 5/Pack
Delivery by Mon, Jun 23
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
Price is $4.69
Delivery by Mon, Jun 23
1-hr pickup
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
Price is $34.89
Unit of measure 100/Box Price per unit $0.35/File Jacket
Delivery by Mon, Jun 23
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
Price is $84.89
Unit of measure 6/Carton Price per unit $14.15/Box
Free delivery by Mon, Jun 23
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
Compare similar items
| Attributes | ComplyRight UB-04 Hospital Claim Form, 500 Forms/Pack (UB04LC5) | ComplyRight Employee Benefits & Insurance Records Organizer, Pack of 25 (A0309) | ComplyRight CMS-1500 Health Insurance Claim Form, 250/Box (CMS12LC250) | ComplyRight™ Expanded Confidential Employee Medical Records Folder, Pack of 25 (A3325) | ComplyRight Employee Warning Notice, Pack of 50 (A2311) |
|---|---|---|---|---|---|
Your product ComplyRight UB-04 Hospital Claim Form, 500 Forms/Pack (UB04LC5) Price is $28.59 |  Price is $77.79 |  Price is $33.19 |  Price is $81.69 |  Price is $67.39 | |
| Reviews | |||||
| Delivery Information | Delivery by Wed, Jul 02 | Free delivery by Tue, Jul 01 | Delivery by Mon, Jun 23 | Free delivery by Tue, Jul 01 | Free delivery by Tue, Jul 01 |
| Available in my store | No | No | No | No | No |
| Length in Inches | 11 | 11.75 | 11 | 11 | 11 |
| Width in Inches | 8.5 | 9.5 | 8.5 | 9 | 8.5 |
| Medical Form Pack Size | 500 | Data not available | 250 | 25 | Data not available |
| Medical Form Type | Health Insurance Claims | Data not available | Health Insurance Claims | Medical Records Folders | Data not available |
| Print Type | Laser | Data not available | Laser | Data not available | Data not available |
| Add To Cart | Add To Cart | Add To Cart | Add To Cart |
Featured Products
Price is $21.95
Delivery by Tue, 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
Price is $20.19
Delivery by Tue, 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
Price is $17.39
Unit of measure 50/Pack
Delivery by Thu, Jun 26
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
Price is $11.59
Delivery by Tue, 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
Price is $45.79
Unit of measure 50/Pack
Free delivery by Thu, Jun 26
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
Price is $26.49
Unit of measure 50/Pack
Delivery by Thu, Jun 26
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
Price is $63.59
Unit of measure 25/Pack
Free delivery by Thu, Jun 26
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
Price is $21.69
Delivery by Tue, 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
Price is $21.19
Unit of measure 50/Pack
Delivery by Thu, Jun 26
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
Price is $49.59
Unit of measure 250/Box
Free delivery by Thu, Jun 26
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
Price is $56.19
Free delivery by Tue, 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
Price is $17.95
Delivery by Tue, 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
Price is $15.09
Unit of measure 50/Pack
Delivery by Thu, Jun 26
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
Price is $33.89
Delivery by Tue, 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
Price is $26.49
Unit of measure 50/Pack
Delivery by Thu, Jun 26
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