Ub 92 Form - Uniform Bill Template

ADVERTISEMENT

APPROVED OMB NO. 0938-0279
2
4 TYPE
3 PATIENT CONTROL NO.
1
OF BILL
6 STATEMENT COVERS PERIOD
5 FED. TAX NO.
8 N-C D.
9 C-I D.
11
7 COV D.
10 L-R D.
FROM
THROUGH
12 PATIENT NAME
13 PATIENT ADDRESS
CONDITION CODES
ADMISSION
31
21 D HR 22 STAT 23 MEDICAL RECORD NO.
14 BIRTHDATE
15 SEX 16 MS
17 DATE
18 HR
19 TYPE
20 SRC
24
25
26
27
28
29
30
36
OCCURRENCE SPAN
37
32
OCCURRENCE
34
OCCURRENCE
35
OCCURRENCE
33
OCCURRENCE
A
A
CODE
DATE
CODE
DATE
CODE
DATE
CODE
DATE
CODE
FROM
THROUGH
a
B
B
b
C
C
39
VALUE CODES
40
VALUE CODES
41
VALUE CODES
38
CODE
AMOUNT
CODE
AMOUNT
CODE
AMOUNT
a
a
b
b
c
c
d
d
42 REV. CD.
43 DESCRIPTION
44 HCPCS / RATES
45 SERV. DATE
46 SERV. UNITS
47 TOTAL CHARGES
48 NON-COVERED CHARGES
49
1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
11
11
12
12
13
13
14
14
15
15
16
16
17
17
18
18
19
19
20
20
21
21
22
22
23
23
52 REL
53 ASG
50 PAYER
51 PROVIDER NO.
54 PRIOR PAYMENTS
55 EST. AMOUNT DUE
56
INFO
BEN
A
B
C
DUE FROM PATIENT
57
58 INSURED’S NAME
59 P. REL 60 CERT. - SSN - HIC. - ID NO.
61 GROUP NAME
62 INSURANCE GROUP NO.
A
A
B
B
C
C
63 TREATMENT AUTHORIZATION CODES
64 ESC 65 EMPLOYER NAME
66 EMPLOYER LOCATION
A
A
B
B
C
C
OTHER DIAG. CODES
67 PRIN. DIAG. CD.
76 ADM. DIAG. CD. 77 E-CODE
78
68 CODE
69 CODE
70 CODE
71 CODE
72 CODE
73 CODE
74 CODE
75 CODE
80
79 P.C.
PRINCIPAL PROCEDURE
81
OTHER PROCEDURE
OTHER PROCEDURE
82 ATTENDING PHYS. ID
CODE
DATE
CODE
DATE
CODE
DATE
A
B
OTHER PROCEDURE
OTHER PROCEDURE
OTHER PROCEDURE
83 OTHER PHYS. ID
A
a
CODE
DATE
CODE
DATE
CODE
DATE
C
D
E
b
OTHER PHYS. ID
84 REMARKS
a
a
B
b
b
c
85 PROVIDER REPRESENTATIVE
86 DATE
x
d
UB-92 HCFA-1450
OCR/ORIGINAL
I CERTIFY THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 2