1 2 3a PAT.

4 TYPE
CNTL # OF BILL
b. MEO.
REC.#
6 STATEMENT COVERS PERIOD 7
5 FEO. TAX NO.
FROM THROUGH

8 PATIENT NAME a 9 PATIENT ADDRESS a

b b e d e
ADMISSION CONDITION CODES 29 ACDT 30
10 BIRTHDATE 11 SEX 12 DATE 13HR 14TYPE 15SRC 16DHR 17STAT 19 21 27
18 20 22 23 24 25 26 28 STATE

31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37

CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH
a a

b b

38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES

CODE AMOUNT CODE AMOUNT CODE AMOUNT
a
b
e
d
42 REV. CD. 43 DESCRIPTION 44 HCPCS / RATE / HIPPS CODE 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49

1 1

2 2

3 3

4 4

5 5

6 6

7 7

8 8

9 9

10 10

11 11

12 12

13 13

14 14

15 15

16 16

17 17

18 18

19 19

20 20

21 21

22 22

23
PAGE OF CREATION DATE 23

52 REL. 53
50 PAYER NAME 51 HEALTH PLAN ID ASG. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI
INFO BEN.

A 57 A

B OTHER B

e PRVID e

58 INSURED'S NAME 59 P. REL 60 INSURED'S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

A A

B B

e e

63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

A A

B B

e e
66 68
DX

69 ADMIT 70 PATIENT 71 PPS 72 73

DX REASON DX CODE ECI
74 PRINCIPAL PROCEDURE b. OTHER PROCEDURE 5 76 ATTENDING NPI QUAL
CODE DATE CODE DATE
LAST FIRST
OTHER PROCEDURE QUAL
77 OPERATING NPI
CODE DATE
LAST FIRST
81CC
80 REMARKS 78 OTHER NPI QUAL
a
b LAST FIRST

e 79 OTHER NPI QUAL

d LAST FIRST
UB-04 CMS-1450 APPROVED OMB NO. 0938-0997 THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL ANO ARE MADE A PART HEREOF.
NUBC"' BUNatlonal Unirotm
Ung Commlttee