Follow the steps to successfully fill out the Ubo4 form.

1. Click ‘Get Form’ button to obtain the Ubo4 form and open it in your preferred editor.
2. In the first section, enter the name and address of the hospital or facility that is submitting the claim in the 'Billing Provider Name & Address' field.
3. If the payment address differs from the billing address, provide that information in the 'Pay to Address' section.
4. For the 'Patient Control Number', input your facility's unique account number assigned to the patient, ensuring it is up to 20 alphanumeric characters.
5. In the 'Medical Record Number' field, enter the number assigned to the patient’s medical record, with a maximum of 30 alphanumeric characters.
6. Enter the 'Type of Bill' as a four-digit code based on the billing category, submitting facility, and frequency.
7. Provide the 'Federal Tax Number', which is the facility's tax identification number.
8. Specify the service period in the 'Statement Covers Period' section, inputting the dates in MMDDYY format.
9. Indicate the number of Administratively Necessary Days in the appropriate field.
10. Fill in the 'Patient Name' exactly as it appears on their Medical Assistance ID card.
11. Enter the patient's complete mailing address, including street address, city, state, and zip code.
12. Input the patient's birth date in MMDDCCYY format.
13. Mark the patient's sex as 'M' for Male, 'F' for Female, or 'U' for unknown.
14. Record the 'Admission Date' using MMDDCCYY format to document the start date of the episode of care.
15. Provide the 'Admission Hour' using the codes listed to signify the patient's entry time.
16. Select the 'Admit Type' from the provided codes that capture the reason for admission.
17. Document the 'Source of Admission' using the corresponding codes for how the patient was referred or admitted.
18. Indicate the 'Discharge Hour' using the same structure as the admission hour.
19. Choose the appropriate 'Patient Discharge Status' code based on the patient’s status upon discharge.
20. For conditions that may influence claims processing, enter the two-digit codes in 'Condition Codes' sections.
21. Provide the two-digit accident state abbreviation in the respective field.
22. Input the accident date in the specified field if applicable.
23. Enter any significant occurrence codes and their dates that may affect claims processing.
24. If necessary, detail the occurrence span of those significant events.
25. Fill in the 'Responsible Party Name and Address' section if applicable.
26. Identify value codes and related amounts that might influence the claim in the corresponding fields.
27. In the 'Revenue Code' section, list the four-digit codes corresponding to each service described.
28. Provide descriptions for each revenue code entry in the next column.
29. For services requiring specific coding (like NDC), ensure you follow the appropriate formats in the 'HCPC' section.
30. Document the 'Service Date' for each itemized service provided.
31. Indicate the 'Service Units' for days or units of service rendered.
32. Enter the total charges for each service and then summarize all charges in respective fields.
33. If applicable, provide information on non-covered charges by the primary payer.
34. In the 'Payer' section, enter the names and corresponding three-digit carrier codes for primary and other payers.
35. Input the 'Health Plan ID', identifying the health plan.
36. Specify if you are releasing information with 'Y' or 'N' in the Release of Information section.
37. Indicate assignment of benefits as 'Y' for yes.
38. List any prior payments from other insurers in the designated field.
39. Estimate the amount due in the respective section.
40. Enter the unique National Provider Identifier for the billing provider.
41. If relevant, provide the 'Other Provider Identifier' to give additional context to the NPI.
42. Record the insured's name and their relationship to the insured in the specific fields.
43. Finish with 'Employer Name' and 'Diagnosis and Procedure Code' fields, entering as outlined.
44. After filling in all sections, save your changes, and consider downloading or printing a copy for your records.

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