UB04-One Part Continuous, Removable Margins, 2500 EA/CT
$209.42
TOPS
Must be purchased in multiples of 1 carton
TOP 59770R
The UB-04 is the form hospitals and institutions use to file a medical claim with the patient's insurance company. Use TOPS UB-04 forms with confidence. They meet the requirements of the Centers for Medicare and Medicaid Services (CMS). 1 part continuous.
Available in increments of 1
- 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
- Health Care Finance Administration format ensures accuracy in reporting all necessary information
- Printed on 20 lb. bond paper
- 9-1/2" x 11"
- Replaces UB-92
- Made in the USA
Item # | TOP 59770R |
---|---|
Length | 9.5 |
Width | 11 |
Color | White |
Templates Available | N |
Load Style | N/A |
Demo Address | N/A |
Paper Weight | 20 lb. |
Acid Free | N/A |
Dimensions | N/A |
Cover | No |
Sheet Count | N/A |
Backing | N/A |
Perforated | N/A |
Perforation Type | NA |
Primary Page Coloring | White |
Number of Sheets per Pad | N/A |
Number of Sheets per Pack | N/A |
Pages Numbered | No |
Pages Consecutively Numbered | No |
Hole Punched | No |
Printed Front and Back | Yes |
Form Type | Medical |
Number of Columns | N/A |
Forms Per Page | 1 |
Number of Entry Lines | N/A |
Form Quantity | 2500 |
Sections | N/A |
Duplicate Page Coloring | N/A |
Triplicate Page Coloring | N/A |
Detached Form Size | 11 x 8.5 |
Sheet Size | 11 x 9.5 |
Form Duplicate | Carbon |
Number of Forms Per Page | 1 |
Ink Color on Form | Red |
Hole Punch Location | N/A |
Compatibility - Describe | Continuous feed printers |
CD Included | No |
Wrap-around Cover | No |
Stub | No |
Time Clock Compatibility | N/A |
Self-Seal | No |
Time Increments | N/A |
Corner and Spine Color | N/A |
Cover Texture | N/A |
Cover Interior Printing | N/A |
Book Size | N/A |
Format | N/A |
Ribbon Bookmark | N/A |
Purchasing Quantity | Must be purchased in multiples of 1 carton |
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