Relationship to Patient / Beneficiary
Relationship Description:
Group/Facility Name:
Individual Provider Name:
Tax ID Number (TIN):
Agency Name:
First Name:
Date of Birth:
Street Address:
City:
State:
Zip Code:
Daytime Phone Number:
Extension:
Daytime Fax number:
Email Address
Name:
SSN:
Name:
Date of Birth:
Street Address:
City:
State:
Zip code:
Group/Facility Name:
Individual Provider Name:
Street Address:
City:
State:
Zip code:
Daytime Phone:
Extension:
Fax Number:
Tax ID Number (TIN):
Have the Services Occurred?
Claim Number(s):
Date of Service From:
Date of Service To:
Authorization/Reference Number(s):
CPT, HCPC or description of Service or Procedure Denied:
Date of Denied Claim or Authorization: