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