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UB-04 Health Insurance Claim Forms
for use by Hospitals and Institutions

Designed for processing on high speed OCR scanning equipment Printed in special red "dropout" ink on 20# paper Available in Laser and Continuous pin feed with up to five parts. All parts are printed on white carbonless stock.

ITEM NUMBER: FORMS/PACK DESCRIPTION Laser UB-04 Forms: UB04LC 2500 LASER CUT SHEET UB04LC1 1000 LASER CUT SHEET UB04 UB04LC500 500 LASER CUT SHEET UB04 Continuous UB-04 Forms: UB041 2500 1-PART CONTINUOUS UB042 2500 2-PART CONTINUOUS UB043 1000 3-PART CONTINUOUS UB044 1000 4-PART CONTINUOUS UB045 1000 5-PART CONTINUOUS As of March 1, 2007 the UB-04 replaced the UB-92. This form is designed for hospitals to file a medical claim with the patient's insurance carrier.

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