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