TOPS UB04 Health Care Form, Revised, HCFA Compliant, 8 1/2" X 11", 2500/Carton (59770R~#|#~s0320918_sc7
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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    • Details

    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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    Specifications
    Specifications table
    Attribute nameAttribute value
    Length in Inches 11
    Medical Form Pack Size 2500
    Number of Parts 1
    Form Size
    		8 1/2" x 11"
    Width in Inches
    		8.5
    Series or Collection
    		UB04 Health Care Form
    Medical Form Type Health Insurance Claims
    True Color
    		White
    Print Type Continuous
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    TOPS UB04 Health Care Form, Revised, HCFA Compliant, 8 1/2" X 11", 2500/Carton (59770R
    Price is $195.39
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    Product specifications table
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    No
    No
    No
    No
    No
    No
    No
    No
    Yes
    Medical Form Pack Size
    2500
    250
    2500
    250
    1000
    500
    250
    500
    2500
    500
    500
    100
    500
    1000
    100
    Medical Form Type
    Health Insurance Claims
    Health Insurance Claims
    Health Insurance Claims
    Health Insurance Claims
    Health Insurance Claims
    Health Insurance Claims
    Consent
    Health Insurance Claims
    Dental Claims
    Health Insurance Claims
    Health Insurance Claims
    Dental Claims
    Dental Claims
    Dental Claims
    Health Insurance Claims
    Length in Inches
    11
    11
    11
    11
    11
    11
    11
    11
    11
    Data not available
    11
    11
    11
    11
    11
    Width in Inches
    8.5
    8.5
    8.5
    8.5
    8.5
    8.5
    8.5
    8.5
    8.5
    Data not available
    8.5
    8.5
    8.5
    8.5
    9.5
    True Color
    White
    White / Red
    White / Red
    White
    White / Red
    White / Red
    Red and White
    White / Red
    White
    White / Blue
    Data not available
    White
    White
    White
    White
    Print Type
    Continuous
    Laser
    Laser
    Laser
    Laser
    Laser
    Continuous
    Laser
    Laser
    Data not available
    Laser
    Laser
    Laser
    Laser
    Data not available
    Number of Parts
    1
    1
    1
    Data not available
    1
    1
    1
    1
    1
    Data not available
    Data not available
    1
    1
    1
    Data not available
    Form Size
    8 1 / 2" x 11"
    Data not available
    8 1 / 2" x 11"
    8 1 / 2" x 11"
    Data not available
    8 1 / 2" x 11"
    8 1 / 2" x 11"
    Data not available
    8-1 / 2" x 11"
    9" x 12.5"
    Data not available
    8-1 / 2" X 11"
    8-1 / 2" x 11"
    8-1 / 2" x 11"
    9 1 / 2" x 11"
    Series or Collection
    UB04 Health Care Form
    Data not available
    CMS-1500
    CMS-1500
    Data not available
    CMS-1500
    Centers for Medicare and Medicaid Services
    Data not available
    Data not available
    CMS-1500
    Data not available
    Data not available
    Data not available
    Data not available
    ADA
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