X hits on this document

24 views

0 shares

0 downloads

0 comments

4 / 8

UB-04 Health Insurance Claim Forms

for Hospitals and Institutions

As of March 1, 2007 the UB-04 replaced the UB-92. The form is designed for hospitals to le a medical claim with the patient’s insurance carrier.

Designed for processing on high speed OCR scanning equipment.

Printed in special red “dropout” ink on basis weight 20# paper.

Available for laser and continuous form pin feed with up to ve parts. All parts are printed on white carbonless stock.

Laser Cut Sheets Item # UB04LC - Single sheet - 2,500 per case

Continuous Forms Item # UB041 - 1 part form - 2,500 per case Item # UB042 - 2 part form - 2,500 per case Item # UB043 - 3 part form - 1,000 per case Item # UB044 - 4 part form - 500 per case Item # UB045 - 5 part form - 500 per case

See our Form Filler Software for UB-04 on page 8

4

Document info
Document views24
Page views24
Page last viewedWed Dec 07 09:01:33 UTC 2016
Pages8
Paragraphs122
Words1932

Comments