UB-04 (CMS-1450) Form

The CMS-1450 form (UB-04) can be used by an institutional provider to bill a Medicare fiscal intermediary (FI) when a provider qualifies for a waiver from ASCA requirement for electronic submission of claims.

Original UB04 claim forms can be obtained from U.S. Government Printing Office

Assistant Superintendent
Department of Acct Rep Division
USGPO Room C-830
Washington, DC 20401

See CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 25 for general form completion instructions.

Submit paper claims to appropriate state address indicated on Mailing Addresses webpage.