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TOPS 59770R UB-04 Hospital Claim Form

1 Part - 11" x 9.50" Form Size - Red Print Color - 2500 / Carton

Item # TOP59770R

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Retail/List price: $186.17
Your price:$106.61 for Carton
You save 43%!

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Inventory last updated: 03/24/2017 8:15am EDT

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  • 9-1/2" x 11"
  • 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
The Manufacturer's Description 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). Continuous forms are printed on 20 lb. bond paper.


Product TypeClaim Form
Brand NameTOPS
ManufacturerTOPS Products
Product ModelUB-04
Product NameUB-04 Hospital Claim Form
Manufacturer Part Number59770R
Manufacturer Website Address
Packaged Quantity2500 / Carton


Number of Parts1
Form Length11"
Form Width9.50"
Environmentally FriendlyYes
Environmental CertificationSFI
Number of Forms per Sheet1
Printed SideFront
Country of OriginUnited States
Recycled Content0%
Assembly RequiredNo
Print ColorRed
Print TechnologyDot Matrix


UPC code025932597701
Alternate code/substitutionTOP59770R
Moore prefix and stock number
Product Classification CodeEFFA
Country of OriginUS
Ready to AssembleN
Recommended substitutions
Old item number
Minority/Women-Owned/Challenged Vendor
Old item number
Special order itemN
Relevant TermsTops,Forms,Claims,UB-04 Continuous Forms 1-part 2-part
 forms & record keeping tops 59770r 1014265165 211344265 top59770r 14111800 0025932597701 025932597701 00025932597701 21954191 p359770r 0780748 top 59770r tops ub-04 hospital claim form 1 part 11" 9.50" form size red print color 2500 / carton SFI UB-04 Hospital Claim Form Claim Form UB-04 No Yes 0
Have a look at the category: Claim Forms

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