Patient Information Sheet Page 2
ADVERTISEMENT
1
2Patient Information Sheet
____ ORIGINAL RX ON FILE
____ SIGNED C.P.S. ON FILE
!
DATE OF SVC: HCPCS CODE:
DESCRIPTION:
CHARGE:
NO. DISP.
!
____________
_____________ ___________________________ _$_______.____
________
____________
_____________ ___________________________ _$_______.____
________
____________
_____________ ___________________________ _$_______.____
________
____________
_____________ ___________________________ _$_______.____
________
TOTAL PRODUCT CHARGES
_$_______.____
ASSIGNED:
YES
NO
SALES TAX:
_$_______.____
DIAGNOSES: _______ ______ ______ ______ TOTAL DUE:
_$_______.____
TOTAL PAID BY PATIENT:
_$_______.____
!
____ Follow-up letter to Doctor (sent ___/___) _____ Include product info.
____ Bill Insurance (submitted ___/___)
_____ Send Directions
____ Call for Rx/CPS/Diag. Code
_____ Call for Prior Approval
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical