Highlights
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- Revised Format
- AMA approved format
- Use TOPS UB-04 forms with confidence
MADE IN AMERICA
TOPS UB04 Health Care Form, Revised, HCFA Compliant, 8 1/2" X 11", 2500/Carton (59770R
Item #: 890389Model #: 59770R
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Final price is $195.39
2500/carton
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Price is $26.29
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About this product
The UB-04 is the form hospitals and institutions use to file a medical claim with the patient's insurance company
- Revised Format
- AMA approved format
- Use TOPS UB-04 forms with confidence
- They meet the requirements of the Centers for Medicare and Medicaid Services (CMS) and are available in Laser and Continuous formats
- Made in the USA
Frequently bought together
Price is $16.99, Regular price was $20.59, You save 17%
Unit of measure 100/Box Price per unit $0.17/File Folder
Delivery by Mon, Jun 09
1-hr pickup
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Over 30
Price is $10.59, Regular price was $12.69, You save 16%
Unit of measure Dozen Price per unit $0.88/Marker
Delivery by Mon, Jun 09
1-hr pickup
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Over 30
Price is $15.69
Unit of measure Dozen Price per unit $0.01/Post-it® Note
Delivery by Mon, Jun 09
1-hr pickup
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Over 30
Price is $16.99, Regular price was $19.59, You save 13%
Unit of measure Dozen Price per unit $1.42/Pad
Delivery by Mon, Jun 09
1-hr pickup
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Over 30
Price is $19.49
Unit of measure 10/Pack Price per unit $1.95/Correction Tape
Delivery by Mon, Jun 09
1-hr pickup
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Over 30
Price is $8.69
Unit of measure 60/Pack Price per unit $0.14/Pen
Delivery by Mon, Jun 09
1-hr pickup
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Over 30
Price is $9.99
Unit of measure 1000/Pack Price per unit $0.01/Paper Clip
Delivery by Mon, Jun 09
1-hr pickup
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Over 30
Price is $8.19
Unit of measure 4/Pack Price per unit $2.05/Correction Tape
Delivery by Mon, Jun 09
1-hr pickup
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Over 30
Price is $27.99, Regular price was $31.69, You save 11%
Unit of measure 250/Box Price per unit $0.11/File Folder
Delivery by Mon, Jun 09
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Over 30
Price is $9.99, Regular price was $11.99, You save 16%
Unit of measure 12/Pack Price per unit $0.83/Pad
Delivery by Mon, Jun 09
1-hr pickup
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Over 30
Price is $20.49
Unit of measure Dozen Price per unit $1.71/Pen
Delivery by Mon, Jun 09
1-hr pickup
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Over 30
Price is $13.99
Unit of measure 144/Pack Price per unit $0.10/Binder Clip
Delivery by Mon, Jun 09
1-hr pickup
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Over 30
Price is $8.69
Unit of measure 12/Pack Price per unit $0.72/Binder Clip
Delivery by Mon, Jun 09
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Over 30
Price is $18.29
Unit of measure 12/Pack Price per unit $1.52/Roll
Delivery by Mon, Jun 09
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Over 30
Price is $7.59
Unit of measure 24/Pack Price per unit $0.32/Binder Clip
Delivery by Mon, Jun 09
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Over 30
Price is $16.99, Regular price was $19.59, You save 13%
Unit of measure Dozen Price per unit $1.42/Pad
Delivery by Mon, Jun 09
1-hr pickup
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Over 30
Price is $17.89
Unit of measure 1000/Pack Price per unit $0.02/Paper Clip
Delivery by Mon, Jun 09
1-hr pickup
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Over 30
Price is $25.99, Regular price was $29.49, You save 11%
Unit of measure 36/Pack Price per unit $0.72/Marker
Delivery by Mon, Jun 09
1-hr pickup
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Over 30
Price is $20.49
Unit of measure 10/Pack Price per unit $2.05/Roll
Delivery by Mon, Jun 09
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Over 30
Price is $30.79
Unit of measure 10/Pack Price per unit $3.08/Box
Delivery by Mon, Jun 09
1-hr pickup
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Compare similar items
| Attributes | TOPS UB04 Health Care Form, Revised, HCFA Compliant, 8 1/2" X 11", 2500/Carton (59770R | ComplyRight CMS-1500 Health Insurance Claim Forms (02/12), 8-1/2" x 11", Pack of 250 (CMS12LC250) | ComplyRight CMS-1500 Health Insurance Claims, 2500/Pack (CMS12LC) | TOPS Centers for Medicare and Medicaid Services Forms, 8-1/2" x 11" (50135RV) | ComplyRight CMS-1500 Health Insurance Claim Forms (02/12), 8-1/2" x 11", Box of 1,000 (CMS12LC1) |
|---|---|---|---|---|---|
Your product TOPS UB04 Health Care Form, Revised, HCFA Compliant, 8 1/2" X 11", 2500/Carton (59770R Price is $195.39 Out of Stock | Price is $26.29 | Price is $89.59 |  Price is $33.69 |  Price is $83.79 | |
| Reviews | |||||
| Delivery Information | Data not available | Delivery by Mon, Jun 16 | Free delivery by Mon, Jun 16 | Delivery by Mon, Jun 09 | Free delivery by Mon, Jun 09 |
| Available in my store | No | No | No | No | No |
| Length in Inches | 11 | 11 | 11 | 11 | 11 |
| Medical Form Pack Size | 2500 | 250 | 2500 | 250 | 1000 |
| Width in Inches | 8.5 | 8.5 | 8.5 | 8.5 | 8.5 |
| Medical Form Type | Health Insurance Claims | Health Insurance Claims | Health Insurance Claims | Consent | Health Insurance Claims |
| True Color | White | White / Red | White / Red | Red and White | White / Red |
| Print Type | Continuous | Laser | Laser | Continuous | Laser |
| Number of Parts | 1 | 1 | 1 | 1 | 1 |
| Form Size | 8 1 / 2" x 11" | Data not available | 8 1 / 2" x 11" | 8 1 / 2" x 11" | Data not available |
| Series or Collection | UB04 Health Care Form | Data not available | CMS-1500 | Centers for Medicare and Medicaid Services | Data not available |
| Add To Cart | Add To Cart | Add To Cart | Add To Cart |
Featured Products
Price is $20.19
Delivery by Tue, Jun 17
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Over 30
Price is $15.59
Unit of measure 10/Pack
Delivery by Thu, Jun 12
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Over 30
Price is $32.09
Unit of measure 100/Pack
Delivery by Thu, Jun 12
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Over 30
Price is $21.19
Unit of measure 50/Pack
Delivery by Thu, Jun 12
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Over 30
Price is $48.09
Unit of measure 50/Pack
Free delivery by Thu, Jun 12
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Over 30
Price is $24.49
Unit of measure 100/Pack
Delivery by Thu, Jun 12
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Over 30
Price is $21.69
Delivery by Tue, Jun 17
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Over 30
Price is $37.89
Unit of measure 50/Pack
Free delivery by Thu, Jun 12
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Over 30
Price is $33.29
Delivery by Tue, Jun 17
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Over 30
Price is $45.79
Unit of measure 25/Pack
Free delivery by Thu, Jun 12
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Over 30
Price is $37.89
Unit of measure 50/Pack
Free delivery by Thu, Jun 12
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Over 30
Price is $45.79
Unit of measure 25/Pack
Free delivery by Thu, Jun 12
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Over 30
Price is $15.69
Unit of measure Dozen Price per unit $0.01/Post-it® Note
Delivery by Mon, Jun 09
1-hr pickup
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Over 30
Price is $36.19
Unit of measure 50/Box
Free delivery by Tue, Jun 17
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Over 30
Price is $25.29
Unit of measure 50/Pack
Delivery by Thu, Jun 12
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