Ub04 Hospital Insurance Claim Form, 8 1-2 X 11, Laser Printer, 2500 Forms
                        BRAND: TOPS™
ITEM: 
TOP59870R
        WEIGHT: 26.0 lb
        
        
        
        
  
    
      
        Printed to Government Printing Office standards. OCR ink for scanning. American Medical Association (AMA) approved format. For Laser Printers. Form Size: 8.5 x 11; Forms Per Page: 1; Form Quantity: 2500; Layout: One Form per Sheet.