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