L P I Information Systems
LPI Information Systems
Toll-Free in USA: (888) 729-2020

DATASMITH   Catalog: Page

US flag
count
Still need it? We've still got it!!  Nobody ships it faster!!!
Human Resource Essentials     Changes for 2018     Form Layouts    TAX FORM CROSS REFERENCE
Need Help? To get email answers 24/7, CLICK HERE: forms@datasmithpayroll.com or Call 1-888-729-2020 for live, Toll-Free help 9am-6pm Central Time

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.
UB041 UB041 UB041
ITEM
NUMBER:
FORMS/PACK DESCRIPTION
Laser UB-04 Forms:
UB04LC 2500 LASER CUT SHEET
UB04LC1 1000 LASER CUT SHEET UB04
UB04LC5 500 LASER CUT SHEET UB04
Continuous UB-04 Forms:
UB041 2500 1-PART CONTINUOUS
UB0411 1000 1-PART CONTINUOUS
UB042 1000 2-PART CONTINUOUS W/W
UB043 1000 3-PART CONTINUOUS - All White
UB044 500 4-PART CONTINUOUS - All White
UB045 500 5-PART CONTINUOUS - All White

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.


Previous Catalog Page Catalog Index Customer Service View Cart ORDER Items on this Page Next Catalog Page

Need large quantity?...different packaging?...Get a competitive Custom Forms Quote!!
We'll e-mail our quote and create a special on-line order page just for you!

Valid W3C HTML 4.01 Transitional Valid CSS!