Form preview

Get the free UB-04 Site Licenses template

Get Form
UB04 Site LicensesSingle Site License The cost for a single site license is the equivalent of 5 manuals ($750). However, site licensees are actually sent only one manual and one user logon/password
We are not affiliated with any brand or entity on this form

Get, Create, Make and Sign ub-04 site licenses template

Edit
Edit your ub-04 site licenses template form online
Type text, complete fillable fields, insert images, highlight or blackout data for discretion, add comments, and more.
Add
Add your legally-binding signature
Draw or type your signature, upload a signature image, or capture it with your digital camera.
Share
Share your form instantly
Email, fax, or share your ub-04 site licenses template form via URL. You can also download, print, or export forms to your preferred cloud storage service.

How to edit ub-04 site licenses template online

9.5
Ease of Setup
pdfFiller User Ratings on G2
9.0
Ease of Use
pdfFiller User Ratings on G2
Use the instructions below to start using our professional PDF editor:
1
Log in. Click Start Free Trial and create a profile if necessary.
2
Simply add a document. Select Add New from your Dashboard and import a file into the system by uploading it from your device or importing it via the cloud, online, or internal mail. Then click Begin editing.
3
Edit ub-04 site licenses template. Replace text, adding objects, rearranging pages, and more. Then select the Documents tab to combine, divide, lock or unlock the file.
4
Save your file. Select it in the list of your records. Then, move the cursor to the right toolbar and choose one of the available exporting methods: save it in multiple formats, download it as a PDF, send it by email, or store it in the cloud.
With pdfFiller, it's always easy to work with documents.

Uncompromising security for your PDF editing and eSignature needs

Your private information is safe with pdfFiller. We employ end-to-end encryption, secure cloud storage, and advanced access control to protect your documents and maintain regulatory compliance.
GDPR
AICPA SOC 2
PCI
HIPAA
CCPA
FDA

How to fill out ub-04 site licenses template

Illustration

How to fill out ub-04 site licenses

01
Gather all necessary information such as facility name, address, and contact details.
02
Enter the type of healthcare facility for which you are filling out the UB-04 site license.
03
Provide the date when the license is being filled out.
04
Enter the effective date and expiration date of the license.
05
Include the billing provider information, such as the provider's name, NPI number, and address.
06
Add the required details of the facility's owner or authorized official.
07
Provide the necessary information related to the type of ownership, such as whether it is a sole proprietorship, partnership, or corporation.
08
Include any additional information required by the licensing authority.
09
Review the completed form for accuracy and ensure all required fields are filled out.
10
Submit the filled-out UB-04 site license to the appropriate licensing authority.

Who needs ub-04 site licenses?

01
Hospitals, including general hospitals, specialty hospitals, and psychiatric hospitals.
02
Skilled nursing facilities and nursing homes.
03
Rehabilitation centers and facilities.
04
Long-term care facilities.
05
Inpatient and outpatient clinics.
06
Home health agencies providing medical services.
07
Hospices providing medical services.
08
Ambulatory surgical centers.
09
Residential treatment facilities.
10
Other healthcare facilities that require billing for services provided.

What is UB-04 Site Licenses Form?

The UB-04 Site Licenses is a fillable form in MS Word extension required to be submitted to the required address in order to provide certain info. It needs to be completed and signed, which can be done in hard copy, or by using a particular software e. g. PDFfiller. It allows to complete any PDF or Word document directly in your browser, customize it according to your purposes and put a legally-binding e-signature. Once after completion, you can send the UB-04 Site Licenses to the appropriate recipient, or multiple recipients via email or fax. The blank is printable too because of PDFfiller feature and options presented for printing out adjustment. Both in digital and in hard copy, your form will have got clean and professional outlook. It's also possible to save it as the template to use later, without creating a new blank form from the beginning. Just customize the ready template.

Instructions for the form UB-04 Site Licenses

Before starting to fill out UB-04 Site Licenses Word template, remember to prepared enough of required information. It is a important part, because some errors can trigger unwanted consequences beginning from re-submission of the whole entire blank and completing with deadlines missed and you might be charged a penalty fee. You need to be careful enough filling out the figures. At first glance, it might seem to be not challenging thing. Nevertheless, it's easy to make a mistake. Some people use some sort of a lifehack storing everything in a separate file or a record book and then put this into sample documents. Nevertheless, come up with all efforts and provide actual and solid data in your UB-04 Site Licenses word template, and doublecheck it when filling out all fields. If it appears that some mistakes still persist, you can easily make amends while using PDFfiller editing tool without missing deadlines.

How should you fill out the UB-04 Site Licenses template

To start completing the form UB-04 Site Licenses, you'll need a writable template. When you use PDFfiller for completion and filing, you can find it in a few ways:

  • Find the UB-04 Site Licenses form in PDFfiller’s library.
  • If you didn't find a required one, upload template with your device in Word or PDF format.
  • Create the document from scratch in PDF creation tool adding all required objects in the editor.

Whatever option you choose, you will get all features you need under your belt. The difference is that the template from the library contains the necessary fillable fields, and in the rest two options, you will have to add them yourself. Nevertheless, this action is quite simple and makes your form really convenient to fill out. These fillable fields can be easily placed on the pages, you can delete them as well. There are different types of these fields depending on their functions, whether you’re entering text, date, or place checkmarks. There is also a e-sign field for cases when you need the document to be signed by others. You are able to put your own signature via signing tool. Upon the completion, all you need to do is press the Done button and pass to the distribution of the form.

Fill form : Try Risk Free
Users Most Likely To Recommend - Summer 2025
Grid Leader in Small-Business - Summer 2025
High Performer - Summer 2025
Regional Leader - Summer 2025
Easiest To Do Business With - Summer 2025
Best Meets Requirements- Summer 2025
Rate the form
4.4
Satisfied
49 Votes

For pdfFiller’s FAQs

Below is a list of the most common customer questions. If you can’t find an answer to your question, please don’t hesitate to reach out to us.

In your inbox, you may use pdfFiller's add-on for Gmail to generate, modify, fill out, and eSign your ub-04 site licenses template and any other papers you receive, all without leaving the program. Install pdfFiller for Gmail from the Google Workspace Marketplace by visiting this link. Take away the need for time-consuming procedures and handle your papers and eSignatures with ease.
To distribute your ub-04 site licenses template, simply send it to others and receive the eSigned document back instantly. Post or email a PDF that you've notarized online. Doing so requires never leaving your account.
Completing and signing ub-04 site licenses template online is easy with pdfFiller. It enables you to edit original PDF content, highlight, blackout, erase and type text anywhere on a page, legally eSign your form, and much more. Create your free account and manage professional documents on the web.
UB-04 site licenses are required for healthcare facilities to bill for services provided to patients.
Healthcare facilities such as hospitals, clinics, and nursing homes are required to file UB-04 site licenses.
UB-04 site licenses can be filled out electronically or manually, following the guidelines provided by the National Uniform Billing Committee.
The purpose of UB-04 site licenses is to standardize billing practices in healthcare facilities and ensure accurate and timely reimbursement for services provided to patients.
Information such as patient demographics, diagnosis codes, procedure codes, and billing details must be reported on UB-04 site licenses.
Fill out your ub-04 site licenses template online with pdfFiller!

pdfFiller is an end-to-end solution for managing, creating, and editing documents and forms in the cloud. Save time and hassle by preparing your tax forms online.

Get started now
Form preview
If you believe that this page should be taken down, please follow our DMCA take down process here .
This form may include fields for payment information. Data entered in these fields is not covered by PCI DSS compliance.