Billing Information

For accurate billing reports, the client must furnish the information required on the requisition form. Patient’s full name and address; date of birth, and referring physician UPIN are the basic information necessary. Any questions regarding billing, please call our facility. 

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Bill Medicare – Check “Bill Medicare” on the test request

  • Name and address of patient
  • Medicare number/ Social Security number
  • Date of birth
  • ICD9 diagnosis code
  • Referring physician’s UPIN
  • Patient signature on the requisition, copy of Medicare card 

Bill Medicaid – Check “Bill Medicaid” on the test request

  • Name and address of patient
  • Medicaid number/ Social Security number
  • MediPass Number
  • Date of birth
  • ICD9 diagnosis code
  • Referring physician’s UPIN
  • Patient signature on the requisition, copy of Medicaid card 

Bill Physician – Check “Bill Physician” on the test request

  • Name of patient

Bill Patient – Check “Bill Patient” on the test request

  • Name and address of patient
  • Name of responsible party if other than patient.
  • Telephone number of the patient.
  • Social Security number 

Bill Insurance

  • Name and address of patient
  • Name of responsible party if other than patient
  • ID Number
  • Group Number
  • ICD9 diagnosis code
  • Employer name
  • Date of birth
  • Copy of insurance card