Health Care Claim Forms
UB-04
The UB-04 is the form hospitals use to file a
medical claim with the patient's insurance company.
This form is available in cut sheet and one to four-part
carbonless continuous.
| UB-04 |
31-0987 |
8.5"x11"
20# |
Laser Cut
Sheet 1 Ply |
| UB-04 |
31-0977 |
9.5"x11"
20# |
Continuous
1/2" Perfs 1 Ply |
| UB-04 |
31-0972 |
9.5"x11" |
Continuous
1/2" Perfs Carbonless All White 2 Ply |
| UB-04 |
31-0973 |
9.5"x11" |
Continuous
1/2" Perfs Carbonless All White 3 Ply |
| UB-04 |
31-0974 |
9.5"x11" |
Continuous
1/2" Perfs Carbonless All White 4 Ply |
|
 |
CMS-1500
The Centers for Medicare and Medicaid Services
requires that all insurance claims sent to Medicare be
submitted on form CMS-1500.
This form is available in cut sheet, one to three-part
carbonless continuous, with or without barcode
| CMS |
31-0980 |
8.5"x11"
20# |
Laser Cut
Sheet 1 Ply |
| CMS |
31-0901 |
9.5"x11"
20# |
Continuous
1/2" Perfs 1 Ply |
| CMS |
31-0902 |
9.5"x11" |
Continuous
1/2" Perfs Carbonless White/Canary 2 Ply |
| CMS |
31-0903 |
9.5"x11" |
Continuous
1/2" Perfs Carbonless All White 3 Ply |
|
ADA Form
The American Dental Association authorizes
dental practitioners to submit this form to the patient's
insurance company.
This form is available in cut sheet and one or two-part
carbonless continuous.
| ADA94 |
31-9840 |
8.5"x11"
20# |
Laser Cut
Sheet 1 Ply |
| ADA94 |
31-9500 |
9.5"x11"
20# |
Continuous
1/2" Perfs 1 Ply |
| ADA94 |
31-9512 |
9.5"x11"
20# |
Continuous
1/2" Perfs Carbonless All White 2 Ply |
|
Transaction Rolls |
Stock Forms |
Custom Forms |
Cut Sheets |
Health Care |
Jumbo Rolls
|
