v1 © 10-2007
FLU SHOT PATIENT - RX
Your Integrated Client Number or your name
IMPORTANT:
PLEASE -
At Least Once Per Session of Claim Entry :
YOUR EMAIL ADDRESS:
PATIENT INFORMATION
.
Patient Full Name
Patient Address
.
City / State / Zip
.
Medicare Part B #
.
D.O.B.
(mm-dd-yy)
Sex
.
Billing Date
.
Make a Vaccine and Admin Claim ?
. ..
YES
.
(when you click the FINISH button below, that's all we need ! )
Click to Submit ->