Intellect™
SAMPLE UB04 FORM
For an overview of the CMS-1450 (aka, the UB04 form), see https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/837I-FormCMS-1450-ICN006926.pdf (as of June 2018).
For information for each field, go to http://www.eohhs.ri.gov/Portals/0/Uploads/Documents/ub04_instructions.pdf.