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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

2

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

4. TYPE OF BILL

5. FED. TAX NO.

6. STATEMENT COVERS FROM THRU

7

8. PATIENTS NAME

a

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 e VALUE AMOUNT CHARGES 49 .

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7 Alignment for Printer to be unlocked after purchase 8. 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. PATIENTS NAME a 9.1 UB-04 Trial Version Use this Page with PrePrinted Paper Click on the Page TABS at the bottom 2 5. 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. TAX NO. FED.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 .

0938-0997 79OTHER LAST NPI QUAL FIRST .c d UB-04 CMS-1450 APPROVED OMB NO.

e AMOUNT CHARGES 49 .

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OTHER PROCEDURE CODE DATE b.1 UB-04 Trial Version Use Plain White Paper Click on the Page TABS at the bottom Alignment for Printer to be unlocked after purchase 2 3a. FED. PAT.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. TAX NO. 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. STATEMENT COVERS FROM THRU 7 8. 6. PRINCIPAL CODE DATE d. PATIENTS NAME a 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. OTHER PROCEDURE CODE DATE e. REC# 4. OTHER PROCEDURE CODE DATE 75 c. CNTL# b. TYPE OF BILL 5.MED. 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 e VALUE AMOUNT CHARGES 49 ..

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