v5 © 12-2006

NEW PATIENT - RX / HME

Use your SHIFT LOCK * one patient

per submission

THIS APPLICATION IS USED FOR NEW PATIENT PROCESSING ONLY.
PROVIDER INFORMATION
Your Integrated Client Number or your name
IMPORTANT:
PLEASE - At Least Once Per Session of Claim Entry :
YOUR EMAIL ADDRESS:
PATIENT INFORMATION
. Patient Name ( last name < space > first name < space >mi) .
Patient Address.
City / State / Zip .
Social Security No.. Date of Birth
Sex. FEMALE. MALE Patient Phone
.    
ARE YOU ACCEPTING ASSIGNMENT ? If this claim is for a Medicare Claim *
YES . . NO * (only non participating Medicare providers may check)
Carrier's Payment Goes To :. PROVIDER . . PATIENT
PRIMARY INSURANCE CARRIER INFORMATION
.
MEDICARE MEDICAID Cash Patient
OTHER For OTHER, please complete remaining fields below :

Primary Insurance Carrier Name

Primary Insurance Carrier Phone No.

Primary Insurance Carrier Address

Primary City / State / Zip

Primary Group No. Policy / Agreement No.
SECONDARY INSURANCE CARRIER INFORMATION
.
MEDICAID MEDICARE for Secondary NONE Patient Responsibility
OTHER For OTHER, please complete remaining fields below :

Secondary Insurance Carrier Name

Secondary Insurance Carrier Phone No.

Secondary Insurance Carrier Address

Secondary City / State / Zip

Secondary Group No. Policy / Agreement No.
PATIENT DIAGNOSIS INFORMATION
.

Medical Diagnosis (ICD-9 or description): ( Click ONE BOX or enter the patients code or a full description )

Insulin Dependent Diabetes - 250.01 Non-Insulin Dependent Diabetes - 250.00 Parkinson's
Congestive Heart Disease Asthma C O P D
OsteoArthritis Cerebral Vascular Disease Decubitus Ulcer
Permanent Incontinence Artificial Opening Colostomy
1:
2:

PHYSICIAN INFORMATION
.

Pharmacy and DME Providers - enter the prescribing physician information. NOTE: if you know you have already sent us the doctor in the past, just give us their name and / or NPI number, then skip remaining fields. If Prescribing Physician is new or being entered for the very first time, enter information for below fields. UPIN NUMBERS ARE NO LONGER REQUIRED.

Prescribing Physician Name

Phone No.

Address

City / State / Zip

Physician NPI No's.
Physician State License No.

.

Will The Claim Need To Be Held For Other Documents? NO YES

( Will we need a copy of the prescription, CMN or other documents from you or the physician ? )

PRODUCT DISPENSED

.

N O T E S : ( If entering Inital Product please provide all info, or use other applications )

  • When entering text, please keep as short as possible.
  • Hit your RETURN KEY after each date please.
  • Enter date : MM - DD - YY or MM / DD / YY
  • Enter -> DATE, PRODUCT, QTY, YOUR AMOUNT to charge.
  • Enter QUANTITY in individual units not BOX ( except where only a box quantity can be dispensed ).

example: 01-15-2001 , drainable ostomy bags Holl. #4454 , 30 ea , $84.50

Date Of Product Delivery

Product Delivered or Message
.
Make This Patient A Diary Billing ? YES. NO ( Look on the Healthcare Menu for more information )
Click to Submit ->