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Get Fillable Ub 04 Claim Form

Dle Initial) 10 BIRTHDATE 11 SEX 12 b DATE 32 OCCURRENCE DATE CODE X X a City ADMISSION 13 HR 14 TYPE 15 SRC 16 DHR 17 STAT MMDDYYYY M/F MMDDYY XX 31 OCCURRENCE CODE DATE 18 19 33 OCCURRENCE DATE CODE 34 OCCURRENCE CODE DATE 4 TYPE OF BILL XXXX 6 5 FED. TAX NO. 7 STATEMENT COVERS PERIOD FROM THROUGH Federal Tax ID DOS From - Through Patient Address c Stated Zip Code 20 XX XX XX Text 3a PAT. CNTL # b. MED. REC. # CONDITION CODES 22 23 24 21 35 CODE 25 26 27.

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