# UB-04 Form

URL: https://pdf.net/pdf-forms/healthcare-forms/ub-04-form
Category: Healthcare Forms
Attributes: Trusted by lawyers

Form UB-04 is used by institutional healthcare providers, such as hospitals, to bill Medicare, Medicaid, and other health insurance companies for services provided to patients.

PDF.net offers a fillable Form UB-04 that you can open in our editor with a single click and fill out with the necessary information. Then, save this submission-ready document to your device.

## Versions

- 2025 — [download PDF](https://cdn.sanity.io/files/i16te7yp/production/d0dd3a7da4f11b154f81f02483c50a840687e60a.pdf)

## How to Fill Out the UB-04 Form

Step 1: Open Form UB-04 in our PDF editor.

Step 2: Fill out information about the patient, as outlined in the Form UB-04 instructions.

Step 3: Write the correct condition and diagnosis codes.

Step 4: Complete the section about the payer and the health plan.

Step 5: Review the document.

Step 6: Submit Form UB-04 to the healthcare insurance company.

## Facts

### What Is the UB-04 Form?

Form UB-04, also known as Form CMS-1450, is a document that institutional medical providers should file to bill Medicare, Medicaid, and other insurance companies for specific services provided. This document can only be used by institutions; non-institutional providers must use Form CMS-1500.

### Who Is Required to Fill Out the UB-04 Form?

Form UB-04 is filled out by institutional healthcare providers, such as hospitals, hospices, nursing facilities, rehabilitation centers, dialysis centers, and home health agencies.

### When Is the UB-04 Form Due?

There is no specific due date for Form UB-04, as the submission deadline differs depending on the insurance company and its requirements. Typically, you’ll be expected to submit the form within a few months after the service has been provided.

### What Are the Penalties for Not Submitting the UB-04 Form?

Penalties for not submitting the UB-04 Form may include the denial of payment for services, which can lead to lost revenue and cash flow issues for the medical institution.

### Where Do I File the UB-04 Form?

You should file Form UB-04 with the patient’s healthcare insurance payer, either electronically or by mail. Submission specifics depend on the insurer, so make sure to read the instructions on their official websites.