UB-04 (1696) 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
41
LENGTH
1
SHORT DESCRIPTION
OTHER DIAG 13 POA (FL-67M/1/2)
