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Home > Office Supplies > Accounting Books > Tops UB-04 Hospital Claim Form

Tops UB-04 Hospital Claim Form

1 Part - 11" x 8.5" Form Size - 2500 / Carton

Tops UB-04 Hospital Claim Form
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Tops UB-04 Hospital Claim Form
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Item No.  746350
Mfg Part No.  59770R
Product Condition:  New
Manufacturer:  Tops

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Highlights for Tops UB-04 Hospital Claim Form
  • Media Quantity:(1 Form Per Sheet)

Marketing Information

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.

General Information

  • Product Type: Claim Form
  • Manufacturer Part Number: 59770R
  • Manufacturer Website Address: www.tops-products.com
  • Packaged Quantity: 2500 / Carton
  • Manufacturer: Tops Products
  • Product Model: UB-04
  • Product Name: UB-04 Hospital Claim Form
  • Brand Name: Tops
  • Miscellaneous



    Recycled Content




    Assembly Required


    Physical Characteristics

    Product Information

  • Color: White
  • Media Quantity: (1 Form Per Sheet)
  • Print Technology: Dot Matrix
  • Print: Front Side Form With Red Ink
  • Form Size: 11" Length x 8.50" Width
  • Number of Parts: 1 Part
  • Powered By GfK Etilize

    Tops UB-04 Hospital Claim Form

    1 Part - 11" x 8.5" Form Size - 2500 / Carton
    Add To Cart

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