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UB-04 (CMS 1450) Health Insurance Claim Form. 

The CMS-1450 form (aka UB-04 at present) can be used by an institutional provider to bill a Medicare fiscal intermediary (FI) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims. It is also used for billing of institutional charges to most Medicaid State Agencies.

  • Box with 2,500 forms.

UB-04 (CMS 1450) Medical Claim Form

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