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 This link will take you to an external website. for general form completion instructions.

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