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a TOPS 59772R UB-04 Continuous Billing Form

TOPS 59772R UB-04 Continuous Billing Form

2 Part - Carbonless Copy - 11" x 9.50" Form Size - Black Print Color - 1000 / Carton

Item # TOP59772R

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Retail/List price: $151.67
Your price:$98.63 for Carton
You save 35%!

Clearance - Discontinued - Non-returnable item
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Inventory last updated: 05/22/2017 11:45am EDT

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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 Continuous Billing Form
Manufacturer Part Number59772R
Manufacturer Website Address
Packaged Quantity1000 / Carton


Number of Parts2
Form Length11"
Form Width9.50"
Carbonless CopyYes
Printed SideFront
Country of OriginUnited States
Recycled Content0%
Assembly RequiredNo
Certifications & Standards

Medicare and Medicaid Services

Print ColorBlack
Print TechnologyLaser
Weight (Approximate)19 lb


UPC code025932597725
Alternate code/substitution
Moore prefix and stock number
Package Weight28
Package Height11.94
Package Length11.25
Package Width9.75
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 Terms
 forms & record keeping tops 59772r 1014309821 14111800 025932597725 top59772r top 59772r 0025932597725 22583606 0691550 p359772r tops ub-04 continuous billing form 2 part carbonless copy 11" 9.50" form size black print color 1000 / carton UB-04 Continuous Billing Form Claim Form UB-04 Perforated No 0
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