UB-04 Billing Claim Form – Paper forms – FREE Priority Shipping

The UB-04 is the standard claim form used by all institutional providers to bill for medical and mental health services.
• Commercially Printed on 8.5″ x 11″ paper – 20 # white bond
• Laser cut sheets for use in inkjet or laser printers
• OCR “dropout” red ink for processing on scanner equipment
• Instructions for government/private health programs on back
• Accommodates National Provider Identifier (NPI) reporting
• Form CMS 1450 (UB-04) OMB Approved – No. 0938-0997

Shrink-wrapped packages. Order 200, 300 or 500 forms.
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The UB-04 Billing Claim Form, also known as the CMS-1450 Form, is the universal paper claim used to bill for medical and mental health services.  The uniform bill (UB) is used by hospitals, nursing homes, hospice, home health agencies, and other institutional providers who are submitting a paper claim. The UB-04 is the only paper claim is accepted by the Centers for Medicare & Medicaid Services (CMS) from institutional providers who qualify for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims.

The UB-04 (CMS-1450)

Any institutional provider can use the UB-04 for billing medical claims.
Institutional providers include hospitals, Skilled Nursing Facilities (SNFs), End Stage Renal Disease (ESRD) providers, Home Health Agencies (HHAs), hospices, outpatient rehabilitation clinics, Comprehensive Outpatient Rehabilitation Facilities (CORFs), Community Mental Health Centers (CMHCs), Critical Access Hospitals (CAHs), Federally Qualified Health Centers (FQHCs), histocompatibility laboratories, Indian Health Service (IHS) facilities, organ procurement organizations, Religious Non-Medical Health Care Institutions (RNHCIs), and Rural Health Clinics (RHCs).

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