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UB-04 Trial Version

Use this Page with Plain White Paper Click on the Page TABS at the bottom Alignment for Printer to be unlocked after purchase

3a. PAT. CNTL# b.MED. REC#

4. TYPE OF BILL

5. FED. TAX NO.

6. STATEMENT COVERS FROM THRU

8. PATIENTS NAME

9. PATIENTS ADDRESS

a c
CONDITION CODES

b
ADMISSION

b
11 SEX 12 DATE 13 HR 14 TYPE 15 SRC 16 DHR 17 STAT 18 19 20 21 22 23 24 25 26 27

d
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29 ACDT STATE

e
30

10 BIRTHDATE

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OCCURRENCE

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OCCURRENCE

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OCCURRENCE

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OCCURRENCE

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OCCURRENCE SPAN

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OCCURRENCE SPAN

CODE

DATE

CODE

DATE

CODE

DATE

CODE

DATE

CODE

FROM

THROUGH

CODE

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37

38

39 CODE

VALUE AMOUNT

42 CODE

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41 CODE

VALUE AMOUNT

a b c d
42 REV CD. 43 DESCRIPTION 44 HCPSC / RATE /HIPPS CODE 45 SERV DATE 46 SERV UNITS 47 TOTAL CHARGES 48 NON COVER CHARGES

UB-04 Trial Version

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50 PAYER NAME

0F
51 HEALTH PLAN ID

CREATION DATE
52RE INFO 53AS BEN

TOTALS
55 EST.AMOUNT DUE 57

0 00
56 NPI

0 00

54 PRIOR PAYMENTS

UB-04 Trial Version UB-04 Trial Version UB-04 Trial Version

58 INSURED'S NAME 59 PREL 60 INSURER'S UNIQUE ID 61 GROUP NAME

OTHER PRV ID 62 INSURANCE GROUP NUMBER

63 TREATMENT AUTHORIZATION CODE

64 DOCUMENT CONTROL NUMBER

65 EMPLOYER NAME

66

68

69 ADMIT DX

70 PATIENT REASON DX

71 PPS CODE

72 EC1

73 76 ATTENDING LAST NPI QUAL FIRST NPI QUAL FIRST NPI QUAL FIRST

74 CODE

PRINCIPAL DATE

a.

OTHER PROCEDURE CODE DATE

b.

OTHER PROCEDURE CODE DATE

75

c.

PRINCIPAL CODE DATE

d.

OTHER PROCEDURE CODE DATE

e.

OTHER PROCEDURE CODE DATE

77 OPERATING LAST

81CC

80 REMARKS

a b

78 OTHER LAST

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UB-04 CMS-1450 APPROVED OMB NO. 0938-0997

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NPI

QUAL FIRST

. TYPE OF BILL

VALUE AMOUNT

CHARGES

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UB-04 Trial Version

Use this Page with PrePrinted Paper Click on the Page TABS at the bottom

5. FED. TAX NO.

Alignment for Printer to be unlocked after purchase

8. PATIENTS NAME a 9. PATIENTS ADDRESS

a c d
28
STATE

b
10 BIRTHDATE 11 SEX 12 DATE

b
13 HR 14 TYPE 15 SRC 16 DHR 17 STAT 18 19 20 21 22 23 24 25 26 27

e
30

CODE

DATE

CODE

DATE

CODE

DATE

CODE

DATE

CODE

FROM

THROUGH

CODE

FROM

THROUGH

38

CODE

AMOUNT

CODE

AMOUNT

CODE

AMOUNT

a b c d
42 REV CD. 43 DESCRIPTION 44 HCPSC / RATE /HIPPS CODE 45 SERV DATE 46 SERV UNITS 47 TOTAL CHARGES 48 NON COVER CHARGES

UB-04 Trial Version

PAGE
50 PAYER NAME

0F
51 HEALTH PLAN ID

CREATION DATE
INFO BEN

TOTALS
55 EST.AMOUNT DUE 57

0 00
56 NPI

0 00

54 PRIOR PAYMENTS

UB-04 Trial Version UB-04 Trial Version UB-04 Trial Version

58 INSURED'S NAME 59 PREL 60 INSURER'S UNIQUE ID 61 GROUP NAME

OTHER PRV ID 62 INSURANCE GROUP NUMBER

63 TREATMENT AUTHORIZATION CODE

64 DOCUMENT CONTROL NUMBER

65 EMPLOYER NAME

66

68

73 CODE DATE CODE DATE CODE DATE 75 76 ATTENDING LAST CODE DATE CODE DATE CODE DATE 77 OPERATING LAST 80 REMARKS NPI NPI QUAL FIRST QUAL FIRST NPI QUAL FIRST

a b

78 OTHER LAST

c d
UB-04 CMS-1450 APPROVED OMB NO. 0938-0997

79OTHER LAST

NPI

QUAL FIRST

AMOUNT

CHARGES

49

UB-04 Trial Version

Use Plain White Paper Click on the Page TABS at the bottom Alignment for Printer to be unlocked after purchase

3a. PAT. CNTL# b.MED. REC#

4. TYPE OF BILL

5. FED. TAX NO.

6. STATEMENT COVERS FROM THRU

8. PATIENTS NAME

9. PATIENTS ADDRESS

a c
CONDITION CODES

b
ADMISSION

b
11 SEX 12 DATE 13 HR 14 TYPE 15 SRC 16 DHR 17 STAT 18 19 20 21 22 23 24 25 26 27

d
28
29 ACDT STATE

e
30

10 BIRTHDATE

31

OCCURRENCE

32

OCCURRENCE

33

OCCURRENCE

34

OCCURRENCE

35

OCCURRENCE SPAN

36

OCCURRENCE SPAN

CODE

DATE

CODE

DATE

CODE

DATE

CODE

DATE

CODE

FROM

THROUGH

CODE

FROM

THROUGH

37

38

39 CODE

VALUE AMOUNT

42 CODE

VALUE CODES AMOUNT

41 CODE

VALUE AMOUNT

a b c d
42 REV CD. 43 DESCRIPTION 44 HCPSC / RATE /HIPPS CODE 45 SERV DATE 46 SERV UNITS 47 TOTAL CHARGES 48 NON COVER CHARGES

UB-04 Trial Version

PAGE
50 PAYER NAME

0F
51 HEALTH PLAN ID

CREATION DATE
52RE INFO 53AS BEN

TOTALS
55 EST.AMOUNT DUE 57

0 00
56 NPI

0 00

54 PRIOR PAYMENTS

UB-04 Trial Version UB-04 Trial Version UB-04 Trial Version

58 INSURED'S NAME 59 PREL 60 INSURER'S UNIQUE ID 61 GROUP NAME

OTHER PRV ID 62 INSURANCE GROUP NUMBER

63 TREATMENT AUTHORIZATION CODE

64 DOCUMENT CONTROL NUMBER

65 EMPLOYER NAME

66

68

69 ADMIT DX

70 PATIENT REASON DX

71 PPS CODE

72 EC1

73 76 ATTENDING LAST NPI QUAL FIRST NPI QUAL FIRST NPI QUAL FIRST

74 CODE

PRINCIPAL DATE

a.

OTHER PROCEDURE CODE DATE

b.

OTHER PROCEDURE CODE DATE

75

c.

PRINCIPAL CODE DATE

d.

OTHER PROCEDURE CODE DATE

e.

OTHER PROCEDURE CODE DATE

77 OPERATING LAST

81CC

80 REMARKS

a b

78 OTHER LAST

c d
UB-04 CMS-1450 APPROVED OMB NO. 0938-0997

79OTHER LAST

NPI

QUAL FIRST

. TYPE OF BILL

VALUE AMOUNT

CHARGES

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