Health Insurance Claims Form, UB-04 CMS 1450

OMB 0720-0013

OMB 0720-0013

This information collection requirement is necessary for a medical institution to claim benefit under the Defense Health Agency, TRICARE, which includes the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS). The information collected will be used by CHAMPUS/TRICARE contractors to determine beneficiary eligibility, other health insurance liability, certification that the beneficiary received the care and that the provider is authorized to receive CHAMPUS/TRICARE payments.

The latest form for Health Insurance Claims Form, UB-04 CMS 1450 expires 2020-08-31 and can be found here.


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