Ub 92 Hcfa 1450 Form – Fill Out and Use This PDF

APPROVED OMB NO. 0938-0279

1

2

3 PATIENT CONTROL NO.

4 TYPE

OF BILL

5 FED. TAX NO.

6 STATEMENT COVERS PERIOD

7 COV D.

8 N-C D.

9 C-I D.

10 L-R D.

11

FROM

THROUGH

12 PATIENT NAME

13 PATIENT ADDRESS

14 BIRTHDATE

15 SEX

16 MS

ADMISSION

21 D HR

22 STAT

23 MEDICAL RECORD NO.

CONDITION CODES

31

17 DATE

18 HR

19 TYPE

20 SRC

24

25

26

27

28

29

30

37

32

OCCURRENCE

33

OCCURRENCE

34

OCCURRENCE

35

OCCURRENCE

36

OCCURRENCE SPAN

CODE

DATE

CODE

DATE

CODE

DATE

CODE

DATE

CODE

FROM

THROUGH

A

A

B

B

C

C

39

VALUE CODES

40

VALUE CODES

41

VALUE CODES

A

CODE

AMOUNT

CODE

AMOUNT

CODE

AMOUNT

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

50 PAYER

51 PROVIDER NO.

52 REL

53 ASG

54 PRIOR PAYMENTS

55 EST. AMOUNT DUE

56

INFO

BEN

57

DUE FROM PATIENT

58 INSURED’S NAME

59 P. REL

60 CERT. - SSN - HIC. - ID NO.

61 GROUP NAME

62 INSURANCE GROUP NO.

A

B

C

63 TREATMENT AUTHORIZATION CODES

64 ESC

65 EMPLOYER NAME

66 EMPLOYER LOCATION

A

B

C

67 PRIN. DIAG. CD.

OTHER DIAG. CODES

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

B

A

B

85 PROVIDER REPRESENTATIVE

86 DATE