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  • Sample Charge Ticket

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    dvictoriava
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    CARE CREDIT CHECK INSURANCE BENEFITS AUTHORIZATION: I hereby authorize my insurance benefits to be paid directly to the physician. I also authorize the release of any information required for the processing of this claim.

    Description originale:

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    CARE CREDIT CHECK INSURANCE BENEFITS AUTHORIZATION: I hereby authorize my insurance benefits to be paid directly to the physician. I also authorize the release of any information required for the processing of this claim.

    Droits d'auteur :

    © All Rights Reserved
    Téléchargez comme PDF ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    173 vues1 page

    Sample Charge Ticket

    Transféré par

    dvictoriava
    CARE CREDIT CHECK INSURANCE BENEFITS AUTHORIZATION: I hereby authorize my insurance benefits to be paid directly to the physician. I also authorize the release of any information required for the processing of this claim.

    Droits d'auteur :

    © All Rights Reserved
    Téléchargez comme PDF ou lisez en ligne sur Scribd
    Signaler comme contenu inapproprié
    sur 1

    Attending Physicians

    Medical Associates John Smith, MD


    1234 Pond Road
    Jane Doe, MD
    Anywhere, USA 55555
    Tax ID:
    Patient Name Social Security # Home Phone Work Phone Cell Phone

    Address City State Postal Code

    √ Description CPT Amount √ Description CPT Amount √ Description Code Amount


    Code Code

    Office Services Injections Supplies

    Procedures Special Procedures

    Diagnosis Codes ICD-9-CM

    454.0 Diagnosis Goes Here

    Description Goes Here AUTHORIZATION TO RELEASE INFORMATION: I

    CARE CREDIT
    Date of Service:_____________________ Total Fee____:__________

    Balance:_______________
    Adjustment:____________
    Payment:______________

    hereby authorize the undersigned Physician to release any Previous Balance:_______


    information to my insurance carrier acquired in the course of

    AMEX
    Date Brand Box Code Size Length Strength Single Pair Color my examination or treatment.

    ___________________________________
    Patient’s Signature MC/VISA
    CHECK
    CASH

    INSURANCE BENEFITS AUTHORIZATION: I hereby


    authorize my insurance benefits to be paid directly to the
    physician, and I am responsible for any non-covered services.
    I also authorize the release of any information required for the
    __________________________________
    Reason for F/U:_____________________

    How Long: 15, 30, 45, 60, 90, 2 hrs, 3 hrs

    processing of this claim.


    F/U:________________weeks/months

    _________________________

    Date of Service:_____________________ Total Fee:______________ Date of Service:_____________________ Total Fee:______________


    Reason for F/U:_____________________ Payment:______________ Reason for F/U:_____________________ Payment:______________
    Adjustment:____________ Adjustment:____________
    __________________________________ __________________________________
    Previous Balance:_______ Previous Balance:_______
    F/U:________________weeks/months Balance:_______________ F/U:________________weeks/months Balance:_______________
    CASH CARE CREDIT CASH CARE CREDIT
    How Long: 15, 30, 45, 60, 90, 2 hrs, 3 hrs How Long: 15, 30, 45, 60, 90, 2 hrs, 3 hrs
    CHECK AMEX CHECK AMEX
    MC/VISA MC/VISA

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