Common use of BILLING FORM Clause in Contracts

BILLING FORM. The SUDRF shall use the Centers for Medicare and Medicaid Services (CMS) 1450 UB-04 billing form (or subsequent editions) for inpatient services, and the CMS 1500 Claim Form for outpatient services. The SUDRF shall identify SUDRF care on the billing form in the remarks block by stating “SUDRF care”.

BILLING FORM. The SUDRF shall use the Centers for Medicare and Medicaid Services (CMS) 1450 UB-04 billing form (or subsequent editions) for inpatient services, and the CMS 1500 Claim Form for partial hospitalization or outpatient services. The SUDRF shall identify SUDRF care on the billing form in the remarks block by stating “SUDRF care”.

BILLING FORM. The SUDRF shall use the Centers for Medicare and Medicaid Services (CMS) 1450 UB-04 billing form (or subsequent editions) for inpatient services, and the CMS 1500 Claim Form (08/2005) claim form for partial hospitalization or outpatient services. The SUDRF shall identify SUDRF care on the billing form in the remarks block by stating “SUDRF care”.

BILLING FORM. The SUDRF shall use the Centers for Medicare and Medicaid Services (CMS) CMS 1450 UB-04 billing form (or subsequent editions) for inpatient services, and the CMS 1500 Claim Form (08/05) claim form for partial hospitalization or outpatient services. The SUDRF shall identify SUDRF care on the billing form in the remarks block by stating “SUDRF care”.