UB-04 (1615)    IB FORM SKELETON DEFINITION (364.6)

Name Value
BILL FORM UB-04
SECURITY LEVEL NATIONAL,NO EDIT
PAGE OR SEQUENCE 1
FIRST LINE NUMBER 55
LOCAL OVERRIDE ALLOWED YES
STARTING COLUMN OR PIECE 26
LENGTH 7
SHORT DESCRIPTION OTHER DIAG CODE 12(FL-67L/1/1)