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UB-04 Claim Form

UB-04 Claim Form

Having replaced the UB-92 on March 1, 2007, the UB-04 form is designed for hospitals, skilled nursing, home health care facilities and other institutional health care providers to file medical claims with the patient's insurance carrier. UB-04 hospital claim forms are available in both laser-cut and one to five part continuous forms. The UB-04 forms are printed in OCR "dropout" red ink on Environmental Paper Alliance (EPA) recycled paper.