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UB-04 Claim Form, CMS-1450 Hospital Claim Form, 8-1/2 x 11
UB-04 Claim Form, CMS-1450 Hospital Claim Form, 8-1/2 x 11

UB-04 Claim Form, CMS-1450 Hospital Claim Form, 8-1/2 x 11", Pack of 500

$ 12.13

Availability: 15 in stock
  • Condition: New
  • MPN: N1AUB04
  • Model: UB-04 Claim Form
  • Restocking Fee: No
  • Country/Region of Manufacture: United States
  • All returns accepted: Returns Accepted
  • Refund will be given as: Money Back
  • Item must be returned within: 30 Days
  • Return shipping will be paid by: Seller
  • Brand: Tops Products

    Description

    UB-04 Claim Form, CMS-1450 Hospital Claim Form, 8-1/2 x 11" Pack of 500. Approved OMB No. 0938-0997. UB-04 laser-cut forms are designed for medical offices to file a claim with the patient's insurance company. Forms are printed to GPO standards in OCR ink on 20 lb. bond. The Health Care Finance Administration format ensures accuracy in reporting all necessary information. Forms meet the requirements of the Centers for Medicare and Medicaid Services (CMS). Laser and inkjet compatible. Replaces the UB-92 form.