UB 04 PDF Template
Fill & Print Health Insurance Claim Form
Type, Print & Save as PDF
The UB-04 PDF Form Filler is ideal for completing the standard claim form used by institutional care practitioners to bill for services. Easy to download and use. Print your first claim in just minutes!
Mac/Windows compatible when using Adobe Reader.
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The Uniform Bill (UB-04) is the standard paper claim form used by institutional providers used in billing multiple third party payers. The UB-04 has been revised by the National Uniform Billing Committee (NUBC) to accept Qualifier Code “0” when designating ICD-10-CM and ICD-10-PCS.
Type in the form fields using Adobe Reader. The screen has the “look and feel” of the original UB-04 designed by the NUBC. Fill fields are highlighted in blue and are tabbed for quick data entry.
Save & re-use your templates over and over. Built-in help menus assist the user in accurately completing the claim.
One-time purchase charge to create unlimited claims.
Install on up to two computers such as home and office.
Institutional Claims Submission
A perfect solution for providers submitting UB-04 paper claims.
Used by hospitals, clinics, ambulatory surgery centers and rehabilitation centers billing insurance companies for services rendered.