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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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Related links
UB92 Claim Form. Facility billing name and address. 2. 3 PATIENT CONTROL NO. 4. TYPE. OF. BILL. 5 FED. TAX NO. 6 STATEMENT COVERS PERIOD. 7 COVD. 8 N-C D. 9Read more
View Information Collection (IC) ; Form and Instruction, OWCP/UB-04, Uniform Billing Form ; Form and Instruction, OWCP/UB-92, Uniform Billing Form