This information is not intended to be a substitute for professional medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified health care provider. Please consult your health care provider with any questions or concerns you may have regarding your condition.
Statements are computer itemized to facilitate reconciliation.
Please insert the Medicare number and copy of the card if possible. Please verify that the patient's name, birth date and address indicated on the accession form is correct. The patient's diagnosis must be included, either by ICD9-CM code or by name. Insert correct numbers on the accession form with patient's address and birth date. If possible, a copy of the card is appreciated.