CMS 1450 (UB 04)

This document appears to be a medical billing form containing fields for patient information, diagnosis codes, procedures performed, dates of service, charges, and other billing details. Key information includes fields for patient name and address, admission date, diagnosis and procedure codes, service dates and units, charges, payer name and ID, and certifications on the reverse side related to billing. The form is used to collect information needed to bill for medical services provided to a patient.