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Instructions for Completing the UB-04 Claim Form

Instructions for Completing the UB-04 Claim Form The UB04 claim form is used to submit claims for inpatient and outpatient services by institutional facilities (for example, outpatient departments, Rural Health Clinics, chronic dialysis and Adult Day Health Care). A UB04 with field descriptions and instructions is included in the link below: UB-04

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