UB-04 Licensing Application v2

Organizational Information

Company Name

Parent Company

Address

City/Town

State/Province

ZIP/Postal Code

Company Website

Contact Information

First

Last

Title

Email Address

Phone

License Type

"Internal Use" means that they are intended to be used within a company, including subsidiaries, and branches. This does not apply to suppliers or second-tier subsidiaries.
"Commercial Use" is a license that allows the company to utilize/embed UB-04 Content and distribute that product or service.

Internal Use License

For what purposes will the UB-04 content be internally used?

How many users at your organization will be internally accessing the UB-04 content or the application that is used within, whether or not they see the UB-04 content directly?

Are you a consulting firm?

Yes

Is your organization a health plan?

Yes

How many covered lives are under your plan?

What type of organization are you?

Will the UB-04 content be utilized within an:

Note: If you will be utilizing UB-04 content within a third-party system, that vendor most likely requires a Distribution License with AHA/Health Forum and you may have to license directly with them.

What is its name?

What UB-04 content do you need to utilize?

UB-04 Electronic Data File

Official UB-04 Data Specification Manual

Commercial Use License

Commerical Use means to utilize the UB-04 codes with other assets in your product or service and redistribution of the UB-04 codes alone is not permitted. Utilizing the UB-04 codes includes access, use, extraction, interpretation or manipulation of the UB-04 codes in or into your product/service to produce or enable output (patient records, data, reports, claims, analytics, books, training materials or the like) that could not be created without the UB-04 embedded in the product/service even if the UB-04 codes may not be visible or directly accessible.

Have you licensed the UB-04 in the past?

When did or will your product(s) launch?

What is the name of your product(s)?

What is the name of your product(s)?
	What is the name of your product(s)?	Item weight

more items

How will your product(s) be distributed?

Who is your intended market?

Is your product for:

Will it be distributed to hospital and healthcare systems; physicians in concierge, group or private practice or other settings; or other types of healthcare professionals?

Yes

Are your customers government agencies?

Yes

List Agency(s)

Are your customers other vendors, software companies, or resellers?

Yes

If your customers are none of the above, please describe.

Please provide a description of each product in sufficient detail to give a conceptual understanding. Describe how the UB-04 codes will be utilized in the product(s).

Attach sample pages and/or screen shots for the product or service showing how the UB-04 materials are used and displayed.

Maximum 10 files.
10 MB limit.
Allowed types: jpg, png, pdf, doc, docx, ppt, pptx.

General

Does your organization use AI Technologies to analyze, manipulate, train, enhance, and/or create derivative outcomes or predictions?

Yes

Note: “AI Technologies” means any and all or technologies with artificial intelligence or machine learning capabilities and any and all technologies that utilize generative artificial intelligence including without limitation deep learning, machine learning, machine-based, and other artificial intelligence technologies, software and systems, including large language models, generative pre-trained transformer, and any and all technologies, software and systems and that can, for a given set of machine- or human-defined objectives, generate information, data and/or content including predictions, recommendations, or decisions influencing the real and/or virtual environments with which such technologies interact.

I confirm that all responses and related documentation submitted as part of the application process are accurate and completed to the best of my knowledge. I agree to notify the AHA/Health Forum if the information changes. Terms and Conditions.

Terms and Conditions

The AHA/Health Forum will provide a template license agreement that reflects the appropriate terms, conditions and royalty fees for your product or service. These terms and conditions were developed to protect the UB-04 intellectual property and ensure that organizations bundling the UB-04 codes within their products or services are treated fairly and equitably regardless of organization size, industry or mission.

The AHA/Health Forum agrees that the information provided by applicants will be kept confidential. As an applicant, I agree to keep the information provided by the AHA/Health Forum confidential.

Signature line

Note: Make sure you have agreed to the above "Terms and Conditions".

Commercial Use License - Description