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Form #: CMS 1450; Form Title: UB-04 Uniform Bill; Revision Date: 2007-03- O.M.B. Expiration Date: 2019-08-31; CMS Manual: N/A; Special Instructions: N/A CLAIM. Tips for Completing the UB04 (CMS-1450) Claim Form. Page 1 of 17. Field. Field description. Field type Instructions. 1. Facility name, Address,. UB-04 CMS-1450 Paper Claim Filing Instructions. The following provider types may bill electronically or use the UB-04 CMS-1450 paper claim form when The UB-04 claim form accommodates the National Provider Identifier (NPI) and has incorporated other important changes. Sample UB-04 forms for inpatient and outpatient claims can be found on pages 3 and 4. The UB-04 claim form includes several fields that accommodate the use of your NPI. PR0041 V1.5 01/25/18. UB-04 CLAIM FORM INSTRUCTIONS. FIELD. NUMBER. FIELD NAME. INSTRUCTIONS. 1. Billing Provider Name &. Address. Enter the UB-04 Claim Form Instructions. FORM LOCATOR NAME. INSTRUCTIONS. 1. Billing Provider Name &. Address. Enter the name and address of the hospital/ The instructions describe what information must be entered in each of the block numbers of the UB-04 CMS-1450 paper claim form. Block numbers notUB-04 Claim Form Instructions. Required (R) fields must be completed on all claims. Conditional (C) fields must be completed if the information applies to the Inside is a blank UB-04 claim form for reference, and information on Medica's requirements for successful completion of the UB-04 claim form. These instructions 24 Dec 2018 UB-04 Claim Form Instructions pv05/30/2017 ii. Change history. Date (mm/dd/yyyy) Description of changes. Pages impacted. 11/26/2007.