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Institutional UB-04 Box Numbers

Updating Institutional UB-04 Claim Forms (Box 1-81)
Box 1 - Billing Provider, Address, Phone Number
Box 2 - Pay-To Name and Address
Box 3a - Patient Control Number
Box 3b - Medical Record Number
Box 4 - Type of Bill
Box 5 - Federal Tax ID
Box 6 - Statement Covers Period
Box 7 - Reserved for Assignment by the NUBC
Box 8a - Patient Identifier
Box 8b - Patient Name
Box 8a, 8b - Patient Identifier and Patient Name
Boxes 9a, 9b, 9c, 9d, 9e - Patient Address
Box 10 - Patient Birth Date
Box 11 - Patient Sex
Box 12 - Admission/Start of Care Date
Box 13 - Admission Hour
Box 14 - Admission Type
Box 15 - Admission Source
Box 16 - Discharge Hour (DHR)
Box 17 - Patient Discharge Status
Box 18-28 - Condition Codes
Box 29 - Accident State
Box 30 - Reserved for Assignment by the NUBC
Box 31-34 Occurrence Code/Date
Box 35 and 36 - Occurrence Span Code/Date
Box 37 - Reserved for Assignment by the NUBC
Box 38 - Responsible Party Name and Address
Box 39, 40, 41 - Value Code/Amount
Box 42 - Revenue Code

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