FOR NEW PATIENTS

Must have:

• Patient’s First and Last Name
• Patient’s address
• Patient’s date of birth
• Patient’s gender

Nice to have:

• Social Security number
• Patient’s phone number
• Patient’s email address

INSURANCE INFORMATION

Must have:

• Insurance name
• Billing claims address
• Insurance ID #
• Insurance group # (if any)

Nice to have:

• Insurance phone number
• Subscriber’s name
• Subscriber’s relationship to the patient
• Subscriber’s date of birth

It is always preferable to obtain copies or scan in copies of patient ID and Insurance Card. Both sides!

IF WORKERS COMP OR AUTO

Must have:

• Insurance name
• Billing claims address
• Date of Accident
• Name of State where injury occurred
• Medical Notes – for service provided (must send with claim)
• Attorney’s name (if there is one)
• Attorney’s address and phone number (if there is one)

Nice to have:

• 1^ST REPORT OF INJURY (always helpful)
• Claim number (if already assigned one)
• Attorney’s LOP (if obtainable)

INFORMATION REQUIRED ON CHARGE SHEETS

OUT PATIENT SERVICES/OFFICE

• Patient name and date of birth
• Date of service
• Location of Service
• Doctor’s signature on charge sheet
• DX codes
• CPT codes
• FOR CONSULTS – Referring Doctor’s name and NPI #
• Authorization number where applicable!

FOR ESTABLISHED PATIENTS

Always ask if any changes with insurance or patient address and phone number.