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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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$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
Frequently bought together
Price is $0.50, Regular price was $3.09, You save 83%
Unit of measure 8/Pack Price per unit $0.06/Pencil
Delivery by Tue, Jul 22
1-hr pickup
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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 Tue, Jul 22
1-hr pickup
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Staples Block Erasers, Pink, 3/Pack (10433-CC) is In-store only
Price is $1.00, Regular price was $3.79, You save 73%
Unit of measure 3/Pack Price per unit $0.33/Eraser
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Unit of measure 5/Pack Price per unit $0.40/Highlighter
Delivery by Tue, Jul 22
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Price is $0.50, Regular price was $2.19, You save 77%
Unit of measure Dozen Price per unit $0.04/Eraser
Delivery by Tue, Jul 22
1-hr pickup
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Price is $9.99, Regular price was $12.69, You save 21%
Unit of measure Dozen Price per unit $0.83/Marker
Delivery by Tue, Jul 22
1-hr pickup
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Over 30
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Unit of measure 10/Pack Price per unit $1.60/Correction Tape
Delivery by Tue, Jul 22
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Price is $6.99, Regular price was $8.69, You save 19%
Unit of measure 60/Pack Price per unit $0.12/Pen
Delivery by Tue, Jul 22
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Over 30
Price is $0.25, Regular price was $0.79, You save 68%
Delivery by Tue, Jul 22
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 Tue, Jul 22
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 Tue, Jul 22
1-hr pickup
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Over 30
Price is $6.99, Regular price was $8.19, You save 14%
Unit of measure 4/Pack Price per unit $1.75/Correction Tape
Delivery by Tue, Jul 22
1-hr pickup
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Price is $9.99
Unit of measure 1000/Pack Price per unit $0.01/Paper Clip
Delivery by Tue, Jul 22
1-hr pickup
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Over 30
Price is $4.29, Regular price was $7.29, You save 41%
Unit of measure 18/Pack Price per unit $0.24/Pencil
Delivery by Tue, Jul 22
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 Tue, Jul 22
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Price is $0.55, Regular price was $2.49, You save 77%
Price per unit $0.55/Folder
Delivery by Tue, Jul 22
1-hr pickup
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Price is $0.55, Regular price was $2.59, You save 78%
Price per unit $0.55/Folder
Delivery by Tue, Jul 22
1-hr pickup
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Price is $8.69
Unit of measure 12/Pack Price per unit $0.72/Binder Clip
Delivery by Tue, Jul 22
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Over 30
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Unit of measure Dozen Price per unit $1.17/Pen
Delivery by Tue, Jul 22
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Over 30
Price is $2.49, Regular price was $7.19, You save 65%
Unit of measure 4/Pack Price per unit $0.62/Highlighter
Delivery by Tue, Jul 22
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 | TOPS CMS-1500 Health Insurance Claims, 500/Pack (TOP 50126RV) | ComplyRight CMS-1500 Health Insurance Claims, 2500/Pack (CMS12LC) | ComplyRight CMS-1500 Health Insurance Claim Forms (02/12), 8-1/2" x 11", Pack of 250 (CMS12LC250) | 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 $50.59 | Price is $89.59 | Price is $26.29 |  Price is $83.79 | |
| Reviews | |||||
| Delivery Information | Data not available | Free delivery by Tue, Jul 22 | Free delivery by Tue, Jul 29 | Delivery by Tue, Jul 29 | Free delivery by Tue, Jul 22 |
| Available in my store | No | No | No | No | No |
| Length in Inches | 11 | 11 | 11 | 11 | 11 |
| Medical Form Pack Size | 2500 | 500 | 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 | Health Insurance Claims | Health Insurance Claims |
| True Color | White | White / Red | White / Red | White / Red | White / Red |
| Print Type | Continuous | Laser | Laser | Laser | Laser |
| Number of Parts | 1 | 1 | 1 | 1 | 1 |
| Form Size | 8 1 / 2" x 11" | 8 1 / 2" x 11" | 8 1 / 2" x 11" | Data not available | Data not available |
| Series or Collection | UB04 Health Care Form | CMS-1500 | CMS-1500 | Data not available | Data not available |
| Add To Cart | Add To Cart | Add To Cart | Add To Cart |
Featured Products
Price is $17.39
Unit of measure 50/Pack
Delivery by Fri, Jul 25
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Price is $15.09
Unit of measure 50/Pack
Delivery by Fri, Jul 25
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Price is $21.95
Delivery by Wed, Jul 30
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Price is $17.39
Unit of measure 50/Pack
Delivery by Fri, Jul 25
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Price is $16.79
Unit of measure 50/Pack
Delivery by Fri, Jul 25
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Price is $38.89
Unit of measure 50/Pack
Free delivery by Fri, Jul 25
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Price is $32.09
Unit of measure 100/Pack
Delivery by Fri, Jul 25
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Price is $21.19
Unit of measure 50/Pack
Delivery by Fri, Jul 25
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Price is $32.09
Unit of measure 100/Pack
Delivery by Fri, Jul 25
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Price is $26.49
Unit of measure 50/Pack
Delivery by Fri, Jul 25
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Price is $45.79
Unit of measure 50/Pack
Free delivery by Fri, Jul 25
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Over 30
Price is $46.99, Regular price was $79.99, You save 41%
Unit of measure 5000/Carton
Free delivery by Tue, Jul 22
1-hr pickup
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Price is $57.29
Unit of measure 50/Pack
Free delivery by Fri, Jul 25
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Price is $58.59
Unit of measure 50/Pack
Free delivery by Fri, Jul 25
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Price is $37.99
Unit of measure 100/Pack
Free delivery by Fri, Jul 25
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