Paper Claim Submission Requirements. All paper UB-04 claims must be submitted on standard red claim forms. Black and white versions of these forms, including photocopied versions, faxed versions and resized representations of the form that do not replicate the scale and color of the form required for accurate OCR scanning, will not be accepted and will be returned with a request to submit on the proper claim form.
To type in your claim use the UB 04 PDF Template
The UB 04 PDF is easy to use – It is laid out just like the UB 04 and is tabbed for easy data entry. Simply type in the form fields, print and save to your computer. This form includes built in help callouts, as well as a link to our community forum, if you have a question about filling in your claim.
See our other health insurance claim forms.