v7 © 12-2008

ENTER A NEW PATIENT

If you don't know what you are doing ,

PLEASE CALL INTEGRATED!

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
Must not be blank-> Client number or 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
2: or a full description

Region D Providers Diabetitic Patients Only - Testing How Many Times A Day?
Physician NAME and 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
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Will The Claim Need To Be Held For Other Documents? . . . NO . . . YES
Message or Notes
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