Fillable ub92 2026

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The document provides detailed instructions for completing the UB-92 hospital claim form, including necessary information such as facility details, patient identification, service descriptions, revenue codes, total charges, and diagnosis codes.

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Click ‘Get Form’ to open the fillable UB-92 in the editor.
In the 'Facility' section, enter the name and address of the facility rendering the service.
For 'Patient Control No.', input the patient/facility account number assigned to this case.
Enter the 'Federal Tax No.' which is a 10-digit number starting with 84 for your facility.
Fill in the 'Statement Covers Period' by entering both the start and end dates of service.
In the 'Patient Name' field, provide the patient's last name followed by their first name.
Complete the 'Patient's Address' section with their current mailing address.
Input the patient's birthdate in MM/DD/YY format and specify their sex (F or M).
Record the 'Admission Date' using MM/DD/YY format.
List all relevant revenue codes and descriptions of services billed in their respective fields.

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