v7 © 12-2008

ENTER A NEW PATIENT
PROVIDER INFORMATION * required field every time
Must not be blank-> Client number or provider name: *
YOUR EMAIL ADDRESS: *
PATIENT INFORMATION
Patient Full Name
Patient Address. City / State / Zip .
D.O.B. (mm-dd-yy) Phone Sex.
PRIMARY INSURANCE CARRIER INFORMATION
MEDICARE MEDICAID OTHER

If OTHER PRIMARY CARRIER, please complete text box at bottom with the address to send claims.
Policy / Agreement No. Plan / Group No.

SECONDARY INSURANCE CARRIER INFORMATION
NONE OTHER (name)

If OTHER SECONDARY CARRIER, please complete text box at bottom with the address to send claims.
Policy / Agreement No. Plan / Group No.

PATIENT DIAGNOSIS & PHYSICIAN INFORMATION
1: enter the patients DX code or a full description
2: enter other DX codes in text area below
Physician NAME and MD NPI
PRODUCT DISPENSED
examples: 01-15-2001 - drainable ostomy bags Holl. #4454 - 30 ea - $84.50 . . . 03-07-07 - 100 LANCETS and 100 STRIPS

Are You Accepting Assignment If This Claim is for Medicare?

YES . . . NO

Carrier's Payment Should Go To:

PROVIDER . . . PATIENT

 

* for inhalation patients

It is now required that we tell Medicare the following information every time:
WHEN was the nebulizer ORIGINALLY DELIVERED to the patient?   orig. delivery date
Does this patient OWN or are they RENTING the nebulizer they use?   OWNED     STILL UNDER RENTAL
 

* for diabetitic patients

We must report to Medicare how many times a day all diabetic patients are ordered to test:
Testing How Many Times A Day?

Message or Notes

text box

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