UB-04 LICENSING QUESTIONNAIRE

The American Hospital Association (AHA) has registered copyrights for the National Uniform Billing Committee Official UB-04 Data Specification Manual; with the United States Copyright Office. The AHA controls access to and use of the manual through a series of license agreements that identify the types of information from the manual that is accessible to each licensee. Health Forum is the business unit of the AHA that manages the licensing operations for the:

 

American Hospital Association
155 North Wacker Drive, Suite 400
Chicago, IL 60606

Email: tcarlson@aha.org
Phone: 312.893.6816

 
Check all categories applicable to your organization's use of UB-04 Codes
Also list the (1) full legal name of your business, corporation or government agency; (2) type of business entity; (3) state and date of incorporation or registration; (4) names of principal officers; (5) length of operation as a business; and (6) parent and subsidiary companies if applicable.
3. Which UB-04 content do you want to use? (check all that apply)
3-A. Product Format (check all that apply)
For example, is the UB-04 content used to verify HIPAA compliance for electronic transactions; process claims or health care benefit plans; in a course curriculum or seminar presentation or handout materials; to provide consulting services, such as in client reports and analysis?
If it is licensed, describe the licensing model, including pricing for each type of license. If the Product or Service is sold through subscription, describe types of subscriptions offered and pricing.
10. Is the service/solution sold through a reseller channel?
11. Check this box if you use UB-04 content.
12-A. If you distribute machine-readable UB-04 content to others, is it:
 
12-B. Does your company use UB-04 content:
12-C.  If your proposed use of UB-04 content includes combining your Product with other third party software, for resale and redistribution, explain insufficient detail below, including applicable licensing scheme.
I confirm that all responses and related documentation submitted as part of the UB-04 License application process are accurate and complete to the best of my knowledge. 1 agree that 1 will notify the American Hospital Association if the information changes. 

Applications will only be reviewed, if fully completed and signed.
 
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