The UB-92 Claim Form

  • Single-click on each pink field to learn what information is required in the given Form Locator (FL). The field will change to yellow once you click on a pink field.
  • Double-click in the informational box to return to the UB-92 form.
  • Single-click on the yellow field to review the information about that Form Locator.
  • Use the vertical and horizontal scroll bars to center images.
Picture of UB-92 Claim Form Indicating Required Fields