v6 © 07-2008

UROLOGIC and INCONTINENT

Use your SHIFT LOCK * one patient

per submission

THIS APPLICATION IS USED FOR AN EXISTING 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:
PRODUCT INFORMATION

.
 .      

.Patient Name

(last name first name mi)

.Date of Delivery

.(MM - DD - YY)

.      

.
 description stock number qty charge

.
 URINARY LEG BAG qty $
BEDSIDE DRAIN BAG DAY OR NIGHT qty $
MALE EXTERNAL CATHETER qty $
INTERMITTENT URINARY CATH qty $
IRRIGATION TRAY W BULB SYR qty $
INCONT PANTS DISPOSABLE (BRIEFS) EA qty $

Only Non-Participating Medicare Providers or claims for other than Medicare patients may use the providers price

.

.ARE YOU ACCEPTING ASSIGNMENT ? If this claim is for a Medicare Claim *

.YES NO * ( only non participating Medicare providers may check NO )

.

Message or Notes

text box

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