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25/70.2/Disposition of Copies of Completed Forms. R. 25/75/General Instructions for Completion of Form CMS-1450 (UB-04). R. 25/75.1/Form Locators 1-15 UB-04 Claim Form Instructions. Required (R) fields must be completed on all claims. Conditional (C) fields must be completed if the information applies to the The Office of Management and Budget and the National Uniform Billing Committee have approved the UB-04 claim form, also known as the CMS-1450 form. CLAIM. Tips for Completing the UB04 (CMS-1450) Claim Form. Page 1 of 17. Field. Field description. Field type Instructions. 1. Facility name, Address,. UB-04 Instructions and Sample Claim Form. Last Updated on January 24, 2019. Any person who knowingly presents a false or fraudulent claim for payment of a UB-04 Claim Form Instructions. FORM LOCATOR NAME. INSTRUCTIONS. 1. Billing Provider Name &. Address. Enter the name and address of the hospital/ 24 Oct 2018 The UB-04 is the uniform billing form for institutional providers. See what information it requires and tips on how to fill it out accurately.PR0041 V1.5 01/25/18. UB-04 CLAIM FORM INSTRUCTIONS. FIELD. NUMBER. FIELD NAME. INSTRUCTIONS. 1. Billing Provider Name &. Address. Enter the Form #: CMS 1450; Form Title: UB-04 Uniform Bill; Revision Date: 2007-03- O.M.B. Expiration Date: 2019-08-31; CMS Manual: N/A; Special Instructions: N/A Inside is a blank UB-04 claim form for reference, and information on Medica's requirements for successful completion of the UB-04 claim form. These instructions include specifications for each form locator (field) on the UB-04 claim form and whether or not Medica requires the field be completed.