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