.
PLEASE NOTE: Small change in the
SELECT PRIMARY CARRIER
area, it's a scroll bar, not check boxes now.
Patient Name
.
LAST, FIRST, MI
Physician
Address
City ,State , Zip
Phone No.
Auth No.
Date of Birth
MM / DD / YYYY
Sex
FEMALE
. . . .
MALE
If Auto / Accident / W Comp - Claim Adjuster Name
If Auto / Accident / W Comp - Claim Number
.
PRIMARY INSURANCE CARRIER INFORMATION
NOTE:
. .
If you can select a primary carrier ->
DO NOT
enter info in the yellow area fields below
. . . . Select One . . . .
Highmark PO BOX 3355 Pittsburgh - P45
Highmark Community Blue / Select Blue - P47
Highmark Keystone Blue - Q56
BC/BS Camp Hill, PA - Q90
Medicare - Exact - P21
Medicaid
UMWA
OTHER
If
Other
, please enter info in the yellow area fields below :
Agreement No.
Group No.
Name of Insured's Relationship to patient:
SELF
SPOUSE
CHILD
PRIMARY INS - If Relationship is not
SLEF
name of Insured:
Name
Primary Carrier Name
Carrier Phone
Carrier Address
City / State / Zip
.
SECONDARY INSURANCE CARRIER INFORMATION
. .
NONE
-
Patient Responsibility
Other
.
If
Other
enter info in pink boxes below:
Agreement No.
Group No.
Name of Insured's Relationship to patient:
SELF
SPOUSE
CHILD
SECO INS - If Relationship is not
SLEF
name of Insured:
Name
Seco Carrier Name
Carrier Phone
Carrier Address
City / State / Zip
.
PATIENT INITIAL DIAGNOSIS INFORMATION
ICD-9 CODES PREFERRED - LIST IN HIGHEST PRIORITY ORDER
1:
2:
3:
4:
Notes
.
.
Click to Submit ->