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TOPS Tops UB-04 Hospital Claim Form
1 Part - 11" x 8.5" Form Size - 2500 / Carton

Item Number: TOP59770R

Package Size: 1 Carton of 2500 Each
UB-04 continuous forms are designed for hospitals to file a claim with the patient's insurance company
List Price $175.49
You Pay: $134.99
Delivery estimate: 8/5/2014
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Tops UB-04 Hospital Claim Form - 1 Part - 11" x 8.5" Form Size - 2500 / Carton
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Description Specifications Reviews
  • UB-04 continuous forms are designed for hospitals 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.

Shipping Weight: 28 lbs.

ColorWhite
Form Size11" Length x 8.50" Width
Media Quantity(1 Form Per Sheet)
Number of Parts1 Part
PrintFront Side Form With Red Ink
Print TechnologyDot Matrix
Product ModelUB-04
Product NameUB-04 Hospital Claim Form
Product TypeClaim Form
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