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:

 
 
Check all categories applicable to your organization's use of UB-04 Codes
United State Options
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.
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-A. If you distribute machine-readable UB-04 content to others, is it:
 
12-B. Does your company use UB-04 content:
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.
12. Answer the following questions if you use UB-04 content in a machine-readable format
One file only.
500 MB limit.
Allowed types: txt rtf pdf doc docx odt ppt pptx odp xls xlsx ods.
 13. Attach sample pages and/or screen shots from the Product or Service showing how UB-04 materials are used and displayed.
One file only.
500 MB limit.
Allowed types: txt rtf pdf doc docx odt ppt pptx odp xls xlsx ods.
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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