Demographic Change Form (Page 3 of 3) in pdf

Demographic Change Form Page 3

ees:

(If you are new to LBS, your set up fee covers the demographics set up)

The Demographics change cannot begin until your payment has been received. Please go to

to make your

payment

*Please note, any past due balance with Larsen Billing must be paid before we can move forward with any Demographics changes.

 $250 (per occurrence) for address, name, business name updates

 $300 (per occurrence) for the above changes, plus a tax ID change

If Client bills Medicaid:

 $300 (per occurrence) for address, name, business name updates

 $350 (per occurrence) for the above changes, plus a tax ID change

Important Note: We will use this information exactly as it appears on this form. Incorrect information could result in delayed payments and

other problems or confusion. Please confirm that all information is accurate. Once information has been entered into our system, additional

fees will apply if changes become necessary.

By signing below I acknowledge the information entered on this form is correct. I also give Larsen Billing Service permission to proceed with

making such changes/additions to my account.

Signature: ______________________________________________

Date: ________________

Print Name: _____________________________________________

Page 3 of 3

Larsen Billing Service – Demographics Change Form

Revised 10/1/2014

Demographic Change Form Page 3