Pre- Admit People 65 or older Disabled ESRD Check- in Ineligible Financial Responsibility Form Introduce Pull Method 501r Referral Room ABN Access RCO TPL Payment Medicare Fin Resp for Non- Covered Payer 06 DOB Reviewed by pt for accurate info Name DOB SSN Patient BCBS Copay Deductible Pending Duration Age Coverage HAR Deposit Encounter Medicare Part A Medicare Part C $1,340 RUBA MOON Patient Class HIPAA Active MSPQ CSN Medicaid HAR 11 Guarantor 05 AGB SSN Benefits COB Check- out Thank You Birthday Rule Confine Address Pre- Admit People 65 or older Disabled ESRD Check- in Ineligible Financial Responsibility Form Introduce Pull Method 501r Referral Room ABN Access RCO TPL Payment Medicare Fin Resp for Non- Covered Payer 06 DOB Reviewed by pt for accurate info Name DOB SSN Patient BCBS Copay Deductible Pending Duration Age Coverage HAR Deposit Encounter Medicare Part A Medicare Part C $1,340 RUBA MOON Patient Class HIPAA Active MSPQ CSN Medicaid HAR 11 Guarantor 05 AGB SSN Benefits COB Check- out Thank You Birthday Rule Confine Address
(Print)
Pre-Admit
People 65 or older
Disabled
ESRD
Check-in
Ineligible
Financial Responsibility Form
Introduce
Pull Method
501r
Referral
Room
ABN
Access
RCO
TPL
Payment
Medicare
Fin Resp for Non-Covered
Payer
06
DOB
Reviewed by pt for accurate info
Name
DOB
SSN
Patient
BCBS
Copay
Deductible
Pending
Duration
Age
Coverage
HAR
Deposit
Encounter
Medicare Part A
Medicare Part C
$1,340
RUBA
MOON
Patient Class
HIPAA
Active
MSPQ
CSN
Medicaid
HAR
11
Guarantor
05
AGB
SSN
Benefits
COB
Check-out
Thank You
Birthday Rule
Confine
Address
