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TOPS 59870R UB-04 Hospital Claim Form

1 Part - 11" x 8.50" Form Size - Red Print Color - 2500 / Carton

Item # TOP59870R

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Retail/List price: $211.25
Your price:$122.16 for Carton
You save 42%!

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 • Office Depot $192.99 (37% savings)


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Inventory last updated: 10/27/2016 7:00am EDT

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If ordering $1000 or more, we may be able to offer further discounts.


  • Replaces the UB-92
  • 11" Length x 8.50" Width; 2500 / Carton
  • Health Care Finance Administration format ensures accuracy in reporting all necessary information
  • Forms are printed to GPO standards in OCR ink on 20 lb. bond
  • Continuous forms are designed for hospitals to file a claim with the patient's insurance company
The Manufacturer's Description UB-04 laser-cut forms are designed for medical offices 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.


Product TypeClaim Form
Brand NameTOPS
ManufacturerTOPS Products
Product ModelUB-04
Product NameUB-04 Hospital Claim Form
Manufacturer Part Number59870R
Manufacturer Website Address
Packaged Quantity2500 / Carton


Number of Parts1
Form Length11"
Form Width8.50"
Environmentally FriendlyYes
Environmental CertificationSFI
Number of Forms per Sheet1
Printed SideFront
Country of OriginUnited States
Recycled Content0%
Assembly RequiredNo
Certifications & Standards

American Medical Association

Print ColorRed
Print TechnologyLaser


UPC code025932598708
Alternate code/substitutionTOP59870R
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,1-part UB-04 Laser-cut Forms
 forms & record keeping tops 59870r 1014265164 14111800 025932598708 211344266 top59870r top 59870r 0025932598708 21954208 0110011 p359870r 00025932598708 tops ub-04 hospital claim form 1 part 11" 8.50" form size red print color 2500 / carton UB-04 Hospital Claim Form Claim Form UB-04 No Yes SFI 0
Have a look at the category: Claim Forms

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