Integrated Billing Smartphone App
v1 © 08-2010
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*. . required field
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. Client Number or Provider Name
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. Your Email Address (once per bacth sent)
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. Patient's Full Name
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.Patient's Street Address
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.City / State / Zip
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.Patient's D.O.B.
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.Patient's Phone
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.Patient's Sex
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 * Primary Insurance
    If not Medicare or Medicaid provide complete carrier address in the memo field below.
 
 Policy / Agreement No.
 
 Plan / Group No.
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.* Secondary Insurance
. . If not Medicare or Medicaid provide complete carrier address in the memo field below.
. NONE
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.Secondary Carrier Name
*
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.Policy / Agreement No.
*
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.Plan / Group No.
 
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.* Patient Diagnosi & Physician
. . Enter the patients DX code or a full description
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.1:
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.2:
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.Physician Name
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.Physician NPI
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.* Product Dispensed
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.....examples:

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

.....03-07-07 - 100 LANCETS and 100 STRIPS

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.* Are You Accepting Assignment If This Claim is for Medicare?

.YES . . . NO

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.* Carrier's Payment Should Go To:

.PROVIDER . . . PATIENT

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.* for inhalation patients
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.When was the nebulizer DELIVERED to the patient?
.orig. delivery date
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.Does this patient OWN or are they RENTING the nebulizer they use?
..OWNED     STILL UNDER RENTAL
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.* for diabetitic patients
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.The doctor has ordered the patient to test how often?
. Testing How Many Times A Day?
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.Memo or Message below
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