Highlights
View all details
- 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
No reviews yet
$195.39
2500/carton
Free Returns
Online. In store. Always free.
Learn More
Suggested alternatives
Price is $34.09
Price is $10.46
Price is $59.79
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
Lenovo V15 G4 15.6" Laptop, Intel Core i7-13620H, 16GB RAM, 512GB SSD, Windows 11 Home (83CC002EUS) is In-store only
Price is $549.99, Regular price was $879.99, You save 37%
See alternate delivery items
30-min pickup
Price is $39.99, Regular price was $79.99, You save 50%
Unit of measure 5000/Carton
Free delivery by Thu, Oct 16
30-min 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 $4.49
Delivery by Thu, Oct 16
30-min pickup
1
1
2
3
4
5
6
7
8
9
10
Price is $6.89
Delivery by Thu, Oct 16
1
1
2
3
4
5
6
7
8
9
10
Price is $89.99
Free delivery by Thu, Oct 16
30-min 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 $14.99, Regular price was $20.59, You save 27%
Unit of measure 100/Box Price per unit $0.15/File Folder
Delivery by Thu, Oct 16
30-min 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 $129.99, Regular price was $299.99, You save 56%
Free delivery by Thu, Oct 16
30-min 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 $6.99, Regular price was $9.44, You save 25%
Unit of measure 500/Ream
Delivery by Thu, Oct 16
30-min 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 $16.99, Regular price was $26.14, You save 35%
Unit of measure 1500/Carton
Delivery by Thu, Oct 16
30-min 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 $49.99, Regular price was $129.99, You save 61%
Free delivery by Thu, Oct 16
30-min 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 $34.99, Regular price was $68.99, You save 49%
Unit of measure 4000/Carton
Delivery by Thu, Oct 16
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 $149.99, Regular price was $319.99, You save 53%
Free delivery by Thu, Oct 16
30-min 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 $7.99
Delivery by Thu, Oct 16
30-min pickup
1
1
2
3
4
5
6
7
8
9
10
Price is $2.69
Price per unit $2.69/Folder
Delivery by Thu, Oct 16
30-min pickup
1
1
2
3
4
5
6
7
8
9
10
Price is $349.99, Regular price was $579.99, You save 39%
Free delivery by Thu, Oct 16
30-min 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 $329.99, Regular price was $529.99, You save 37%
Free delivery by Fri, Oct 17
30-min 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 $139.99, Regular price was $179.99, You save 22%
Free delivery by Thu, Oct 16
30-min 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
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", Box of 1,000 (CMS12LC1) | ComplyRight CMS-1500 Health Insurance Claim Form, 250/Box (CMS12LC250) | TOPS Centers for Medicare and Medicaid Services Forms, 8-1/2" x 11", 250/Pack (50135RV) | ComplyRight CMS-1500 Health Insurance Claim Forms (02/12), 8-1/2" x 11", Pack of 500 (CMS12LC500) |
|---|---|---|---|---|---|
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 $85.89 | Price is $34.09 |  Price is $34.59 |  Price is $48.09 | |
| Reviews | |||||
| Delivery Information | Data not available | Free delivery by Thu, Oct 16 | Delivery by Thu, Oct 16 | Delivery by Thu, Oct 16 | Free delivery by Wed, Oct 22 |
| Available in my store | No | No | No | No | No |
| Medical Form Pack Size | 2500 | 1000 | 250 | 250 | 500 |
| Medical Form Type | Health Insurance Claims | Health Insurance Claims | Health Insurance Claims | Consent | Health Insurance Claims |
| Length in Inches | 11 | 11 | 11 | 11 | 11 |
| Width in Inches | 8.5 | 8.5 | 8.5 | 8.5 | 8.5 |
| True Color | White | White / Red | White | Red and White | White / Red |
| Print Type | Continuous | Laser | Laser | Continuous | Laser |
| Number of Parts | 1 | 1 | Data not available | 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 $16.95
Delivery by Fri, Oct 24
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 Fri, Oct 24
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 Tue, Oct 21
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 $33.39
Unit of measure 50/Pack
Delivery by Tue, Oct 21
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 $21.95
Delivery by Fri, Oct 24
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 $166.39
Free delivery by Fri, Oct 24
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 $59.59
Free delivery by Fri, Oct 24
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 $33.29
Delivery by Fri, Oct 24
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 $36.19
Unit of measure 50/Box
Free delivery by Fri, Oct 24
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 Fri, Oct 24
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 Fri, Oct 24
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 $57.29
Free delivery by Fri, Oct 24
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 $15.99
Unit of measure 10/Pack
Delivery by Tue, Oct 21
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 $21.89
Unit of measure 25/Pack
Delivery by Tue, Oct 21
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 $37.79
Unit of measure 25/Pack
Free delivery by Tue, Oct 21
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