Sample filled b4 form 2026

1. Click ‘Get Form’ to open the sample filled b4 form in the editor.
2. Begin by entering the patient’s name in Box 2, ensuring it is formatted as Last Name, First Name, Middle Initial.
3. Fill in the patient’s birth date in Box 3 using the MM/DD/YY format. This is crucial for identifying age-related coverage.
4. In Box 5, provide the complete address of the patient, including city, state, and ZIP code. Avoid using a P.O. box.
5. Indicate the relationship of the patient to the insured in Box 6 by selecting from options like Self, Child, or Spouse.
6. Complete Boxes 10 and 11 to specify if the condition is related to employment or an accident. This helps determine coverage eligibility.
7. Ensure that all signatures are provided where required in Boxes 12 and 31 to authorize payment and release of information.

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