UB-04 Overview. ICN 006926. What is the UB-04? The UB-04, also known as the Form CMS-1450, is the uniform institutional provider hardcopy claim form suitable for use UB-04 CMS-1450 7 10 BIRTHDATE 11 SEX CMS 1450 UB 04 Author: Highmark Medicare Services Subject: UB04 Claim Form Created Date: 5/11/2007 2:49:23 PM Download Or Email Form UB04 & More Fillable Forms, Register and Subscribe Now!Convert PDF to Word,Edit PDF Documents Online,Online Document Editor Fill Ub04 Form, download blank or editable online. Sign, fax and printable from PC, iPad, tablet or mobile with PDFfiller Instantly No software. Try Now! Shop for UB-04 Forms from the Supplies Shops. Order today and save on your hospital claim forms with free shipping on orders over $99. UB-04 claim form and instructions AmeriHealth HMO, Inc. • AmeriHealth Insurance Company of New Jersey • QCC Insurance Company d/b/a AmeriHealth Insurance Company. Fill Free Fillable Ub 04 Form, download blank or editable online. Sign, fax and printable from PC, iPad, tablet or mobile with PDFfiller Instantly No software. Get Amazing Volume Pricing Deals. Order UB-04 Forms, $99+ Shops Free!Index & Fileback Dividers,End Tab Folders,Checks & Security Paper
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