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Tops UB04 Hospital Insurance Claim Form One-Part 8.5 x 11 2500 Forms 59870R

Tops UB04 Hospital Insurance Claim Form One-Part 8.5 x 11 2500 Forms 59870R
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TOPS™ UB04 Hospital Insurance Claim Form

Printed to Government Printing Office standards. OCR ink for scanning. American Medical Association (AMA) approved format. Laser Printer Compatible. Form Type Details: UB04; Dated/Undated: Undated; Forms Per Page: 1; Form Size: 8.5 x 11.

  • Form Type Details: UB04
  • Global Product Type: Insurance Forms
  • Dated/Undated: Undated
  • Forms Per Page: 1
  • Form Size: 8.5 x 11
  • Format Indicator: Unbound
  • Form Quantity (Total): 2,500
  • Copy Types: One-Part (No Copies)
  • Paper Color(s): White
  • Color Family: White
  • Printer Compatibility: Laser
  • Paper Stock: 20 lb Bond
  • Print and Ruling Color(s): Red
  • Product Biodegradability in Days: 0
  • Pre-Consumer Recycled Content Percent: 0%
  • Post-Consumer Recycled Content Percent: 0%
  • Total Recycled Content Percent: 0%
  • Special Features: Laser Printer Compatible

WARNING: This product can expose you to chemicals including Di(2-ethylhexyl)phthalate (DEHP), which is known to the State of California to cause cancer and birth defects or other reproductive harm. For more information, go to www.P65Warnings.ca.gov.
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Shipping Restrictions
  • This item cannot be shipped to PO Boxes.
  • This item can be shipped only within the U.S.


  • UPC: 025932598708 
  • Mfr's Part #: 59870R