UB 04 PDF Template

Fill & Print Health Insurance Claim Form

The Universal Claim Form

Try the UB04 (UB92) Template for Free!

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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Try the full function UB 04 PDF Demo

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.

User Highlights

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    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.

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    Save & re-use your templates over and over. Built-in help menus assist the user in accurately completing the claim.

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    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.

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Easy Claims Submission

Type, print & save to your computer

Type in the Claim

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    To get started, simply open the form with Adobe Reader on a Mac or Windows computer and start typing. The text appears as black 10 pt Arial font, required for paper claim submission.

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    Each field displays detailed callout instructions from the NUBC manual to avoid common billing errors.
    Callouts indicate required and situational fields required for claims processing.

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    Paper claims are now encouraged to be typed, which are scanned using Optical Character Recognition (OCR) to avoid payment errors. The red form color is invisible to the scanner.

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    The UB-04 PDF Template is designed to print just the typed text on a commercially printed claim form that you already have.

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    Paper Claim Required

    The UB-04 takes up the entire paper and cannot be printed correctly using a standard office printer. Need the UB-04 Claim form? Consider our billing package below!

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    Put a Commercially Printed UB-04 Paper Claim in the printer and choose print from the menu. The form is aligned to place the text in the proper spaces.

Prints Typed Text

Aligned for paper claim forms you place in the printer.

Save to Computer

Each claim is saved as PDF.

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    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.

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    Save on up to two computers, such as home and office. Easily open, edit and resave the template over and over. Correct claims quickly if they are rejected for missing, incomplete or invalid information.

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    Keep Protected Health Information (PHI) safe by following your computer safeguards to meet HIPAA Security Rules.
    The UB-04 PDF is never filled or saved online, keeping information confidential.

Purchase Options



One Time Purchase
  • Type, Print & Save as PDF
  • Create Unlimited Claims
  • Prints Text Only
  • Install on 2 Computers
  • Adds up Charges Automatically
  • 200 Red Paper Claim Forms
  • Free Priority Mail Shipping
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Immediate Download  after Purchase with Credit Card or PayPal.
For any questions regarding our pricing plans above, don’t hesitate to contact us!