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Get Ub 04 Form

ODE DATE 33 OCCURRENCE DATE CODE 11 11 A3 12/24/2007 01/18/2008 19 20 34 OCCURRENCE CODE DATE 35 CODE 05/07/2008 74 2 38 CONDITION CODES 24 22 23 21 25 26 27 HI 28 d 96777 e 29 ACDT 30 STATE 20 7 31 OCCURRENCE CODE DATE b 777 Seventh St. c 18 7 STATEMENT COVERS PERIOD FROM THROUGH Anywhere ADMISSION 13 HR 14 TYPE 15 SRC 16 DHR 17 STAT DATE a TYPE OF BILL 211 6 5 FED. TAX NO. 8 PATIENT NAME b 14 000002 01/20/2008 3 36 CODE OCCURRENCE SPAN FROM THROUGH.

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