UB-04 CLAIM FORM INSTRUCTIONS. FIELD NUMBER FIELD NAME INSTRUCTIONS 1. Billing Provider Name & Address Enter the name and address of the hospital/facility submitting the claim. 2 Pay to Address Pay to address if different than field 1. 3a Patient Control Number Enter your facility's unique account number. UB-04 data field requirements Field location UB-04 Description Inpatient Outpatient 1 Provider Name and Address Required Required. • Do not include handwriting anywhere on the claim form. • Do not use stamped data in any field (NPI, provider names, signatures, corrections, etc.).
Sample Ub4 Form
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UB-04 (CMS-1450) form filler software, allows you to fill out UB-04 forms on your PC. EDI claims to a clearinghouse (electronically submit) in Print Image format. Saves and loads claims to your hard drive. Prints on pre-purchased UB-04 forms OR print the entire form in either color or black and white. Create templates for speed of completion and to eliminate repetition. A simple interface with Help boxes for ease of use. AutoFill for repetitive transactions in Rows 1-22.
