• 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
Final price is $195.39
2500/carton

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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

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    Product specifications table
    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)
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    Price is $195.39
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    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
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