UB-04 NOTICE: THE SUBMITTER OF THIS FORM UNDERSTANDS THAT MISREPRESENTATION OR

FALSIFICATION OF ESSENTIAL INFORMATION AS REQUESTED BY THIS FORM, MAY SERVE AS

THE BASIS FOR CIVIL MONETARY PENALTIES AND ASSESSMENTS AND MAY UPON CONVICTION
INCLUDE FINES AND/OR IMPRISONMENT UNDER FEDERAL AND/OR STATE LAW(S).

Submission of this claim constitutes certification that the billing 9. For TRICARE Purposes:
information as shown on the face hereof is true, accurate and
complete. That the submitter did not knowingly or recklessly (a) The information on the face of this claim is true, accurate and
disregard or misrepresent or conceal material facts. The following complete to the best of the submitter’s knowledge and belief,
certifications or verifications apply where pertinent to this Bill: and services were medically and appropriate for the health of
the patient;
1. If third party benefits are indicated, the appropriate (b) The patient has represented that by a reported residential
assignments by the insured /beneficiary and signature of address outside a military medical treatment facility
the patient or parent or a legal guardian covering catchment area he or she does not live within the catchment
authorization to release information are on file. area of a U.S. Public Health Service medical facility, or if the
Determinations as to the release of medical and financial patient resides within a catchment area of such a facility, a
information should be guided by the patient or the copy of Non-Availability Statement (DD Form 1251) is on file,
patient’s legal representative. or the physician has certified to a medical emergency in any
2. If patient occupied a private room or required private instance where a copy of a Non-Availability Statement is not
nursing for medical necessity, any required certifications on file;
are on file. (c) The patient or the patient’s parent or guardian has responded
directly to the provider’s request to identify all health
3. Physician’s certifications and re-certifications, if required insurance coverage, and that all such coverage is identified
by contract or Federal regulations, are on file. on the face of the claim except that coverage which is
exclusively supplemental payments to TRICARE-determined
4. For Religious Non-Medical facilities, verifications and if benefits;
necessary re-certifications of the patient’s need for (d) The amount billed to TRICARE has been billed after all such
services are on file. coverage have been billed and paid excluding Medicaid, and
the amount billed to TRICARE is that remaining claimed
5. Signature of patient or his representative on certifications, against TRICARE benefits;
authorization to release information, and payment (e) The beneficiary’s cost share has not been waived by consent
request, as required by Federal Law and Regulations (42 or failure to exercise generally accepted billing and collection
USC 1935f, 42 CFR 424.36, 10 USC 1071 through 1086, 32 efforts; and,
CFR 199) and any other applicable contract regulations, is (f) Any hospital-based physician under contract, the cost of
on file. whose services are allocated in the charges included in this
bill, is not an employee or member of the Uniformed Services.
6. The provider of care submitter acknowledges that the bill For purposes of this certification, an employee of the
is in conformance with the Civil Rights Act of 1964 as Uniformed Services is an employee, appointed in civil service
amended. Records adequately describing services will be (refer to 5 USC 2105), including part-time or intermittent
maintained and necessary information will be furnished to employees, but excluding contract surgeons or other
such governmental agencies as required by applicable personal service contracts. Similarly, member of the
law. Uniformed Services does not apply to reserve members of
the Uniformed Services not on active duty.
7. For Medicare Purposes: If the patient has indicated that (g) Based on 42 United States Code 1395cc(a)(1)(j) all providers
other health insurance or a state medical assistance participating in Medicare must also participate in TRICARE
agency will pay part of his/her medical expenses and for inpatient hospital services provided pursuant to
he/she wants information about his/her claim released to admissions to hospitals occurring on or after January 1,
them upon request, necessary authorization is on file. 1987; and
The patient’s signature on the provider’s request to bill (h) If TRICARE benefits are to be paid in a participating status,
Medicare medical and non-medical information, including the submitter of this claim agrees to submit this claim to the
employment status, and whether the person has employer appropriate TRICARE claims processor. The provider of care
group health insurance which is responsible to pay for the submitter also agrees to accept the TRICARE determined
services for which this Medicare claim is made. reasonable charge as the total charge for the medical
services or supplies listed on the claim form. The provider of
8. For Medicaid purposes: The submitter understands that care will accept the TRICARE-determined reasonable charge
because payment and satisfaction of this claim will be even if it is less than the billed amount, and also agrees to
from Federal and State funds, any false statements, accept the amount paid by TRICARE combined with the cost-
documents, or concealment of a material fact are subject share amount and deductible amount, if any, paid by or on
to prosecution under applicable Federal or State Laws. behalf of the patient as full payment for the listed medical
services or supplies. The provider of care submitter will not
attempt to collect from the patient (or his or her parent or
guardian) amounts over the TRICARE determined reasonable
charge. TRICARE will make any benefits payable directly to
the provider of care, if the provider of care a participating
provider.
 __ __ __

1 2 3a PAT. 4 TYPE
CNTL # OF BILL
b. MED.
REC. #
__

6 STATEMENT COVERS PERIOD 7

5 FED. TAX NO.
FROM THROUGH

8 PATIENT NAME a 9 PATIENT ADDRESS a

b b c d e

10 BIRTHDATE 11 SEX ADMISSION CONDITION CODES 29 ACDT 30

12 DATE 13 HR 14 TYPE 15 SRC 16 DHR 17 STAT 18 19 20 21 22 23 24 25 26 27 28 STATE

31 OCCURRENCE 32 OCCURRENCE 33 OCCURRENCE 34 OCCURRENCE 35 OCCURRENCE SPAN 36 OCCURRENCE SPAN 37

CODE DATE CODE DATE CODE DATE CODE DATE CODE FROM THROUGH CODE FROM THROUGH

38 39 VALUE CODES 40 VALUE CODES 41 VALUE CODES

CODE AMOUNT CODE AMOUNT CODE AMOUNT
a
b
c
d
42 REV. CD. 43 DESCRIPTION 44 HCPCS / RATE / HIPPS CODE 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
PAGE OF CREATION DATE TOTALS 23

52 REL. 53 ASG.
50 PAYER NAME 51 HEALTH PLAN ID 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 NPI
INFO BEN.

A 57 A

B OTHER B

C PRV ID C

58 INSURED’S NAME 59 P. REL 60 INSURED’S UNIQUE ID 61 GROUP NAME 62 INSURANCE GROUP NO.

A A

B B

C C

63 TREATMENT AUTHORIZATION CODES 64 DOCUMENT CONTROL NUMBER 65 EMPLOYER NAME

A A

B B

C C

66
DX 67 A B C D E F G H 68

I J K L M N O P Q
69 ADMIT

74
DX
70 PATIENT
REASON DX
PRINCIPAL PROCEDURE a.
aOTHER PROCEDURE
b b.
c 71 PPS
CODE
OTHER PROCEDURE 75
72
ECI
73

76 ATTENDING NPI QUAL

CODE DATE CODE DATE CODE DATE
LAST FIRST
c. OTHER PROCEDURE d. OTHER PROCEDURE e. OTHER PROCEDURE QUAL
CODE DATE CODE DATE CODE DATE 77 OPERATING NPI

LAST FIRST
81CC
80 REMARKS 78 OTHER NPI QUAL
a
b LAST FIRST

c 79 OTHER NPI QUAL

d LAST FIRST
UB-04 CMS-1450 APPROVED OMB NO. THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.

NUBC
™
National Uniform
Billing Committee
LIC9213257