Which item is included in Provider Information on the UB-04 form?

Which item is included in Provider Information on the UB-04 form?

• A. Pay-to name and address
• B. Type of Bill
• C. Provider name and address
• D. Patient Control Number

Answer: (C)

Provider Information identifies who delivered the services and where they are located. The item that goes in this area is the provider name and address, which lets the payer know exactly which facility or clinician billed for the services and how to contact them if needed. Pay-to name and address belongs to a separate Pay-To section used when another entity is submitting the claim on behalf of the provider, not the original provider’s identity. Type of Bill is a classification field that indicates the claim’s purpose or type, not who provided the service. The Patient Control Number is a patient-specific tracking identifier assigned by the facility, not part of the provider’s identifying information.

Provider Information identifies who delivered the services and where they are located. The item that goes in this area is the provider name and address, which lets the payer know exactly which facility or clinician billed for the services and how to contact them if needed.

Pay-to name and address belongs to a separate Pay-To section used when another entity is submitting the claim on behalf of the provider, not the original provider’s identity. Type of Bill is a classification field that indicates the claim’s purpose or type, not who provided the service. The Patient Control Number is a patient-specific tracking identifier assigned by the facility, not part of the provider’s identifying information.