pital.
HOSPITAL TAX ID: __________________
PATIENT DEMOGRAPHICS
Patient: ____________________________________ Date of Birth: ______________________
Home Phone: _______________________________ Work / Cell Phone: ________________________
REQUESTED SERVICES
99183 G0277 (# of 30-minute Increments) _____________
ICD-10 Code 1: ______________ ICD-10 Code 2:______________
HBO Physician: _____________________________ NPI__________________________________
Protocol: ______________________________ Anticipated Treatments: ___________________
INSURANCE
Primary: ___________________________¬______ Secondary: _______________________________
Policy #: ___________________________¬______ Policy #: _________________________________
Group #: _________________________________ Group #: _________________________________
Subscriber: _______________________________ Subscriber: _______________________________
Relationship to patient: ______________________ Relationship to patient: ______________________
Insurance Phone ____________________________ Insurance Representative_________________________
Insurance Effective Date:_______________ Hyperbaric Benefits: Yes No
Deductible Yes No Deductible Amount_________________ Deductible Met
Co-payment Yes No Co-payment Amount________________(specify amount or percent)
Authorization Required Yes No Predetermination Required Yes No
Authorization Number _______________________________________________________________________________
Authorization Date Range: ___________________________ Number of visits Authorized________________________
Authorization Number _______________________________________________________________________________
Authorization Date Range: ___________________________ Number of visits Authorized________________________
Comments:
