Health provider on-line billing form

NOTE: This form may only be used for recurring patients. If you wish to submit charges for a new patient, please fax the new patient information to our intake fax at (360) 343-0513. Information on a new patient must include, patient name, complete address, ssn, date of birth, 12 digit medicaid number, and diagnosis.

Enter your 7 digit provider id:
Enter your client's first name:
Enter your client's birthdate: / /

Type of Service:




Visit



Month



Day



Year



Units


Group
(HQ)		 2nd
Visit
Same
Day
(U2)		 3rd +
Visit
Same
Day
(U3)

49-64
Units
(U4)


EPSDT
(U5)

Adult
PDN
(U6)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Billing Entity:
.
Your Initials:

Comments:

   

We bill our clients every other month.
If your bill goes unpaid more than thirty days past that,
it could interrupt your claims submission. Thank you.

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