Scan Medical Insurance

ub04 claimform jpg

ub04 claimform jpg

Summary: NJ Health members IMPORTANT When a referral form is required by Horizon NJ Health please attach the original to the CMS 1500 HCFA 1500 or the UB 04 claim form submitted for payment UB 04 Claim Form R

Image Dimensions: 440 x 586

Image originally found here.