UB 04 PDF Template
Fill & Print Health Insurance Claim Form
The Universal Claim Form
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 UB-04 is the only paper claim 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 PDF is used by hospitals, nursing homes, hospice, home health agencies, and other institutional providers who are submitting a paper claim.
Type, Print & Save as PDF
User Highlights
- Easy to Use: Open in Adobe Reader and start typing. The form looks exactly like the UB-04 on the computer screen.
- Efficient: Save & re-use your templates over and over. Built-in form calculations add up the service charges for you.
- Affordable: One-time purchase charge to create unlimited claims. Install on up to 2 computers such as home and office.
Using the Fillable UB 04 Claim Form
Getting Started
To get started, open the form with Adobe Reader on your Mac or Windows computer and type in the fields. The PDF has the “look and feel” of the original UB-04. The fill fields are positioned to match the field placement grid on the standard claim.
Easy Data Entry
The familiar layout is highlighted in blue and tabbed for fast data entry. Each field includes detailed instructions to help the user avoid common billing errors. Adds up service charges automatically.
Mac & Windows
This PDF is designed to work with Adobe Reader software, the free and trusted PDF viewer. Type, each claim on your computer, not online or in the cloud.
Type in the Claim
There are 81 fields on a UB-04, often referred to as Form Locators (FL).
Print the Claim
Print the typed text onto a red claim form
Saving the Claim
Once you have completed the claim, save each claim with a unique file name. You can create unlimited claims using the UB-04 PDF. Create your own office or patient templates to save time and avoid payment errors.
Save on up to two computers, such as home and office. Easily open, edit and resave the template over and over.
Keep Protected Health Information (PHI) safe by following your computer safeguards to meet HIPAA Security Rules.
Save to Computer
The UB-04 PDF is saved safely to your Mac or PC hard drive, keeping confidential patient information offline.