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The UB-04 claim form may be used by institutional healthcare providers for submitting insurance claims. Also known as the CMS-1450 form, Ub 04 Claim Form. Fill out, securely sign, print or email your ub04 form instantly with SignNow. The most secure digital platform to get legally binding, The UB-04 form serves as a bill which displays and summarizes the cost of all the medical services a patient is given at the time of their treatment. The Download Fillable Form Ub-04 (cms1450) In Pdf - The Latest Version Applicable For 2021. Fill Out The Uniform Bill Online And Print It Out For Free. Ub04 Claim Forms. Fill out, securely sign, print or email your 04 ub form instantly with SignNow. The most secure digital platform to get legally binding, The UB-04 claim form accommodates the National Provider. Identifier (NPI) and has incorporated other important changes. Sample UB-04 forms for inpatient and Sample UB-04 forms for inpatient and outpatient claims can be found on pages 4 and 5. If you have any questions regarding the UB-04 claim form, please call your Statement (DD Form 1251) is on file, or the physician has certified SEE nubc.org/ FOR MORE INFORMATION ON UB-04 DATA ELEMENT AND PRINTING UB-04 Claim Form Instructions. FORM LOCATOR NAME. INSTRUCTIONS. 1. Billing Provider Name &. Address. Enter the name and address of the hospital/facility.