UB04 Field 1: Rendering Provider Name and AddressUB04 Field 2: Pay-To Provider Name and AddressUB04 Field 3a: Patient Control NumberUB04 Field 3b: Medical Record NumberUB04 Field 5: Federal Tax NumberUB04 Field 6: Statement Covers PeriodUB04 Field 7: Future UseUB04 Field 8b: Patient NameUB04 Field 8a: Patient NameUB04 Field 9: Patient AddressUB04 Field 10: Patient BirthdateUB04 Field 12: Admission Date
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