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UB-04 Hospital Claim Form for Laser Printers

Item: 683689   Model: UB04LC
$68.99 2,500/Box

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  • Easily file a medical claim with a patient's insurance carrier
  • File a hard copy of each claim with patient records in case you need to resubmit a claim
  • Compatible with laser printers

Laser forms are printed with red ink on 20-lb. paper.

The UB-04 contains a number of improvements and enhancements that include better alignment with the electronic HIPAA ASC X12N 837-Institutional Transaction Standard. The New UB-04 paper billing form will be able to accommodate the reporting of the National Provider Identifier (NPI) Number. The NPI will be a single provider identifier, replacing the different provider identifiers healthcare systems currently use for each health plan with which you do business. The NPI Identifier, which implements a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), must be used by all HIPAA covered entities, which are health plans, healthcare clearinghouses, and healthcare providers.

  • Easily file a medical claim with a patient's insurance carrier
  • File a hard copy of each claim with patient records in case you need to resubmit a claim
  • Compatible with laser printers

HR Form TypeHealth Insurance Claims

HR Form Pack Size2500

Width in Inches8.5

Number of Parts1

True ColorWhite

Pack Qty1

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