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The UB-04 form serves as a bill which displays and summarizes the cost of all the medical services a patient is given at the time of their treatment. The UB-04 NOTICE: THE SUBMITTER OF THIS FORM UNDERSTANDS THAT MISREPRESENTATION OR FALSIFICATION. OF ESSENTIAL INFORMATION AS REQUESTED BY THIS FORM, MAY SERVE AS Sample UB-04 forms for inpatient and outpatient claims can be found on pages 4 and 5. If you have any questions regarding the UB-04 claim form, please call your The UB04 claim form is used to submit claims for inpatient and outpatient services by institutional facilities (for example, outpatient departments, Rural UB-04 Claim Form Instructions. FORM LOCATOR NAME. INSTRUCTIONS. 1. Billing Provider Name &. Address. Enter the name and address of the hospital/facility.Note: For hospitals using the UB-04 form, it is best practice to confirm the correct revenue and procedure codes with the payer to ensure reimbursement. Sample UB-04 forms for inpatient and outpatient claims can be found on pages 3 and 4. The UB-04 claim form and NPI. The UB-04 claim form includes several