UB04-One Part Continuous, Removable Margins, 2500 EA/CT

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
More Information
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
Compatible With: 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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