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