Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5

Health Insurance Claims Form, UB-04 CMS 1450

Documents and Forms

Document Name Document Type
Form CMS-1450 (UB04) Fr Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5 Form and Instruction
CMS-1450 (UB04) Fr Uniform Institutional Providers Form CMS-1450 UB04-front.pdf Form and Instruction
CMS-1450 (UB04) Ba Uniform Institutional Providers Form CMS-1450 UB04 - Back.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Medicare Uniform Institutional Provider Bill and Supporting Regulations in 42 CFR 424.5	Agency IC Tracking Number:

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 424.5

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-1450 (UB04) Front	Uniform Institutional Providers Form	CMS-1450 UB04-front.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-1450 (UB04) Back	Uniform Institutional Providers Form	CMS-1450 UB04 - Back.pdf		Yes	Yes	Fillable Fileable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10,318	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	858,881	0	858,881
Annual IC Time Burden (Hours)	8,589	1,395	7,194
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.