Guarantor HIPPA Patient DOB Payer RCO HAR Thank you ICN Demographics D Coverage VA EPIC Commercial Payment Nurse Deductible BCBS Check- out CPT Address Pre- Admit ROI Religion Email Customer Service Check- in Deposit Allowed Amount WQ'S Hospital PPO Appointment Desk Cigna Subscriber Subscriber Ineligible Room Clinic Advanced Directive Referral Co- Pay Tricare Active Medicare COB ESTIMATE Admit Medicaid Encounter Authorization and Service Term Doctor PCP Pending Lab Effective Date PFFS Aetna Age Consent Ethnicity Access TPL Registration Discharge SELF- PAY Patient Station Authorization Living Will Co- Insurance Co- Insuranc Guarantor HIPPA Patient DOB Payer RCO HAR Thank you ICN Demographics D Coverage VA EPIC Commercial Payment Nurse Deductible BCBS Check- out CPT Address Pre- Admit ROI Religion Email Customer Service Check- in Deposit Allowed Amount WQ'S Hospital PPO Appointment Desk Cigna Subscriber Subscriber Ineligible Room Clinic Advanced Directive Referral Co- Pay Tricare Active Medicare COB ESTIMATE Admit Medicaid Encounter Authorization and Service Term Doctor PCP Pending Lab Effective Date PFFS Aetna Age Consent Ethnicity Access TPL Registration Discharge SELF- PAY Patient Station Authorization Living Will Co- Insurance Co- Insuranc
(Print)
Guarantor
HIPPA
Patient
DOB
Payer
RCO
HAR
Thank you
ICN
D
Coverage
VA
EPIC
Commercial
Payment
Nurse
Deductible
BCBS
Check-out
CPT
Address
Pre-Admit
ROI
Religion
Email
Customer Service
Check-in
Deposit
Allowed Amount
WQ'S
Hospital
PPO
Appointment Desk
Cigna
Subscriber
Ineligible
Room
Clinic
Advanced Directive
Referral
Co-Pay
Tricare
Active
Medicare
COB
ESTIMATE
Admit
Medicaid
Encounter
Authorization and Service Term
Doctor
PCP
Pending
Lab
Effective Date
PFFS
Aetna
Age
Consent
Ethnicity
Access
TPL
Registration
Discharge
SELF-PAY
Patient Station
Authorization
Living Will
Co-Insuranc
