95df6556-b97f-401b-a4b2-e066ce0ec1ca
  • TOP59870R
  • Item #: TOP59870R
  • Your Price:
    $224.72   CT

  • TOPS 1-part UB-04 Laser-cut Forms - 1 Part - 11" x 8.50" Form Size - Red Print Color - 2500 / Carton
    • Continuous forms are designed for hospitals to file a claim with the patient's insurance company
    • Forms are printed to GPO standards in OCR ink on 20 lb. bond
    • Health Care Finance Administration format ensures accuracy in reporting all necessary information
    • 11" Length x 8.50" Width; 2500 / Carton
    • Replaces the UB-92

Ships in 1-2 Bus Days
  • UB-04 laser-cut forms are designed for medical offices to file a claim with the patient's insurance company. The Health Care Finance Administration format ensures accuracy in reporting all necessary information. Forms meet the requirements of the Centers for Medicare and Medicaid Services (CMS). Forms are printed on 20 lb. bond paper.

  • Country: US
General Information
Manufacturer TOPS Products
Manufacturer Part Number 59870R
Brand Name TOPS
Product Model UB-04
Product Name 1-part UB-04 Laser-cut Forms
Marketing Information

UB-04 laser-cut forms are designed for medical offices to file a claim with the patient's insurance company. The Health Care Finance Administration format ensures accuracy in reporting all necessary information. Forms meet the requirements of the Centers for Medicare and Medicaid Services (CMS). Forms are printed on 20 lb. bond paper.

Packaged Quantity 2500 / Carton
Product Type Claim Form
Product Information
Number of Forms per Sheet 1
Form Length 11"
Form Width 8.50"
Number of Parts 1
Printed Side Front
Print Color Red
Print Technology Laser
Physical Characteristics
Color White
Miscellaneous
Certifications & Standards

American Medical Association

Recycled No
Assembly Required No
Environmentally Friendly Yes
Environmental Certification SFI
Country of Origin United States
  Description Price Qty
  1. TOP59770R
  2. TOPS UB-04 Continuous Forms - 1 Part - 11" x 9.50" Form Size - Red Print Color - 2500 / Carton
    • UB-04 1-part continuous is a form that hospitals use to file a claim with the patient's insurance company
    • Forms are printed to GPO standards in OCR ink on 20 lb. bond
  3. Ships in 1-2 Bus Days
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