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 Type | Claim Form |
|---|---|
| Is Special Price PLA | No |
| SKU | TOP59770R |
| Manufacturer | TOPS Products |
| Manufacturer Part Number | 59770R |
| Brand Name | Tops |
| Product Model | UB-04 |
| Packaged Quantity | 2500 / Pack |
| Product Type | Claim Form |
| Color | White |
| Form Size | 11" Length x 8.50" Width |
| Number Of Parts | 1 Part |
| Front Side Form With Red Ink | |
| Print Technology | Dot Matrix |
| Height In Inches | 11.25 |
| Width In Inches | 9.75 |
| Length In Inches | 11.94 |
| Recycled | No |
| Green Compliant | Yes |
| Green Compliance Certificate/Authority | SFI |