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DATASMITH   Catalog: Page 79

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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.
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.


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