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Get BHI Completing The UM-92 Hospital Claim Form

L No., enter patient/facility account number. Federal Tax No., enter facilities federal tax number, this is your 10 digit number starting with 84. Statement covers period, enter the from date and through date. Patient name, enter last, first. Patients address. Birthdate, enter patient’s date of birth. Sex; enter patient’s sex (F or M). Admission Date, (MM, DD, YY). Mailing address of Patient. Revenue codes, internal codes of facility. Description of service billed. HCPC/rates, enter room and.

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