UB 04 PDF Template

Fill & Print Health Insurance Claim Form


Institutional providers bill for services based on the CMS-1450 also known as the UB-04

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.


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.

 UB04 Facility Billing Software for Nursing Homes, Hospitals,and Institutions.

Type in the Claim

There are 81 fields on a UB-04, often referred to as Form Locators (FL).



CMS 1450 UB04 Medical Billing forms

Print the Claim

Print the typed text onto a red claim form

  • Print Options

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

  • Put a commercially printed UB-04 paper claim in the printer. The form is aligned to place the text in the proper spaces.

  • Paper Claim Required

    Need to purchase the UB-04 paper claims? Consider our billing package that includes 200 or 500 paper claims.


  • 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.



UB-04 Claim Form Software

Save to Computer

The UB-04 PDF is saved safely to your Mac or PC hard drive, keeping confidential patient information offline.

Purchase Options

UB 04 PDF WITH FORM CALCULATIONS

$35

One Time Purchase
  • Create & Save Unlimited Claims
  • Type, Print & Save Claim as PDF
  • Install on 2 Computers
  • Adds up Charges Automatically
Buy & Download