Factura

__
1 2

__
3a PAT. CNTL # b. MED. REC. #
5 FED. TAX NO.

__
4 TYPE OF BILL

__

6

STATEMENT COVERS PERIOD FROM THROUGH

7

8 PATIENT NAME
b

a

9 PATIENT ADDRESS

a c d 28
e

b 11 SEX 12 DATE ADMISSION 13 HR 14 TYPE 15 SRC 16 DHR 17 STAT 18 19 20 21 CONDITION CODES 24 22 23 25 26 27

10 BIRTHDATE

29 ACDT 30 STATE

31 OCCURRENCE CODE DATE
a b

32 OCCURRENCECODE DATE

33 OCCURRENCE DATE CODE

34 OCCURRENCE CODE DATE

35 CODE

OCCURRENCE SPAN FROM THROUGH

36 CODE

OCCURRENCE SPAN FROM THROUGH

37
a b

38

39 CODE

VALUE CODES AMOUNT

40 CODE

VALUE CODES AMOUNT

41 CODE

VALUE CODES AMOUNT

a b c d
42 REV. CD.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

43 DESCRIPTION

44 HCPCS / RATE / HIPPS CODE45 SERV. DATE

46 SERV. UNITS

47 TOTAL CHARGES

48 NON-COVERED CHARGES

49
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22

PAGE
50 PAYER NAME

OF
51 HEALTH PLAN ID

CREATION DATE
52 REL. INFO
53 ASG. BEN.

TOTALS
55 EST. AMOUNT DUE

23

54 PRIOR PAYMENTS

56 NPI 57
OTHER PRV ID
A B C

A B C

58 INSURED’S NAME
A B C

59 P REL 60 INSURED’S UNIQUE ID.

61 GROUP NAME

62 INSURANCE GROUP NO.
A B C

63 TREATMENT AUTHORIZATION CODES
A B C

64 DOCUMENT CONTROL NUMBER

65 EMPLOYER NAME
A B C

66 DX

69 ADMIT 70 PATIENT DX REASON DX PRINCIPAL PROCEDURE a. 74 CODE DATE

67 I

A J

OTHER PROCEDURE CODE DATE

B K a

b

C L
b. e.

c

71 PPS CODE OTHER PROCEDURE CODE DATE

D M

E N
75

72 ECI

F O a
76ATTENDING
NPI

G P b
NPI

H Q c
QUAL
FIRST

68

73

LAST
c.
OTHER PROCEDURE CODE DATE

d.

OTHER PROCEDURE DATE CODE 81CC a
b c d

OTHER PROCEDURE CODE DATE

77 OPERATING

QUAL
FIRST

LAST
80 REMARKS 78 OTHER
NPI

QUAL
FIRST

LAST
79 OTHER
NPI

QUAL
FIRST

LAST

UB-04 CMS-1450 © 2005 NUBC

OMB APPROVAL PENDING

NUBC

™

National Uniform BillingCommittee

LIC9213257

THE CERTIFICATIONS ON THE REVERSE APPLY TO THIS BILL AND ARE MADE A PART HEREOF.

F245-367-000

RESET

UB-04 NOTICE:

THE SUBMITTER OF THIS FORM UNDERSTANDS THAT MISREPRESENTATION OR FALSIFICATION OF ESSENTIAL INFORMATION AS REQUESTED BY THIS FORM, MAY SERVE AS THE BASIS FOR CIVIL MONETARTY PENALTIES AND ASSESSMENTS AND MAY UPON CONVICTION INCLUDE FINES AND/ORIMPRISONMENT UNDER FEDERAL AND/OR STATE LAW(S).

Submission of this claim constitutes certification that the billing information as shown on the face hereof is true, accurate and complete. That the submitter did not knowingly or recklessly disregard or misrepresent or conceal material facts. The following certifications or verifications apply where pertinent to this Bill: 1. If third party benefits areindicated, the appropriate assignments by the insured /beneficiary and signature of the patient or parent or a legal guardian covering authorization to release information are on file. Determinations as to the release of medical and financial information should be guided by the patient or the patient’s legal representative. 2. If patient occupied a private room or required private nursing formedical necessity, any required certifications are on file. 3. Physician’s certifications and re-certifications, if required by contract or Federal regulations, are on file. 4. For Religious Non-Medical facilities, verifications and if necessary recertifications of the patient’s need for services are on file. 5. Signature of patient or his representative on certifications, authorization to releaseinformation, and payment request, as required by Federal Law and Regulations (42 USC 1935f, 42 CFR 424.36, 10 USC 1071 through 1086, 32 CFR 199) and any other applicable contract regulations, is on file. 6. The provider of care submitter acknowledges that the bill is in conformance with the Civil Rights Act of 1964 as amended. Records adequately describing services will be maintained and necessary...