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Blank UB-04 Hospital Billing Form
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We are providing electronic versions of the UB-04 Forms for your use. We are providing two different versions in case one works better for you than the other. (Both versions should work for all, but since everyone has a different browser and operating system set-up, we wanted to give you options.)

UB-04 Form

For this version of the forms, once you fill in the form, click the “I’m finished!” button at the very bottom of the form. Then you can do either of the following:

  • Save the file as a PDF document to your computer.
  • Print the file so that you have a hardcopy.

Now, you can either email the electronic version or hand in your hardcopy to your instructor. (Please note that you will not be able to edit the form once you click the “I’m finished!” button, and will need to start the form over instead.)

UB-04 Form (565.0K)

You can fill in this version of the forms electronically, using Adobe Form Filler, as long as you have Adobe Acrobat Reader. (If you need the latest version of the free reader, you can download it from ***Do not try to complete the form within your browser. First, save the file to your computer. Once you have completed the form, be sure to select “save as” from the File menu and re-name the file per your instructor’s direction (or use this naming convention: You can then print the form or email it to your instructor as needed.

Hospital BillingOnline Learning Center

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