UB 04 PDF Template

Fill & Print Health Insurance Claim Form

The Universal Claim Form

The UB-04 PDF Form Filler is ideal for typing into the standard claim form to bill for services. Easy to download and use – For Mac or PC.

UB-04 Billing Claim Form (CMS-1450) is used for facility and ancillary paper billing. Approved by the Centers for Medicare & Medicaid Services (CMS) and the National Uniform Billing Committee (NUBC).

Download the UB 04 PDF

User Highlights

  • Easy

    Open in Adobe Reader and start typing. The looks exactly like the UB 04 on the computer screen.

  • Efficient

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

  • Affordable

    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.

Using the Fillable UB 04 Claim Form

Type in the Claim

Fill fields highlighted in blue.

  • Type

    To get started, simply open the form with Adobe Reader on a Mac or Windows computer and start typing.

  • Fill fields are highlighted in blue and tabbed for quick data entry. Charges totaled automatically.

  • Each field displays detailed callout instructions from the NUBC manual to avoid common billing errors.

  • Print

    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 paper claims.

Print out the Claim

Print typed text onto a red claim form.

Save to Computer

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

  • Save

    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.

Purchase Options