v1 © 05-2007

NEW PATIENT - RX / HME

If you don't know what you are doing ,

DON'T USE THIS APPLICATION !

Use your <TAB> key to move down the fields.

DO NOT Use the <ENTER KEY> UNTIL DONE.
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 Full Name
Patient Address.
City / State / Zip .
Social Security No.. D.O.B. (mm-dd-yy)
Sex. 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 is the assumed default if nothing is entered
MEDICARE MEDICAID OTHER

For OTHER CARRIERS, please complete text box at bottom
Policy / Agreement No.
SECONDARY INSURANCE CARRIER INFORMATION
.
Enter-> N for none, or the other carrier name
For OTHER, CARRIERS please complete text box at bottom
PATIENT DIAGNOSIS INFORMATION
.

Medical Diagnosis - enter the patients DX ode or a full description
1:
2:
PHYSICIAN INFORMATION
.

Physician NAME and NPI No's.
Will The Claim Need To Be Held For Other Documents? NO YES
PRODUCT DISPENSED

examples:

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

03-07-07 - IAPRAT - 300ml - 13.20

03-07-07 - 100 LANCETS - ( if no money is entered we will use fee schedule amount )

UP TO SIX (6) Product(S) Delivered Lines

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Message or Notes
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