New Billing Rule Form

New Billing Rule Request Form

New Billing Rule Request Form

Please fill out all required sections on this form and submit

MEDENT Account Number:*

Directory (if multiple directories):

Trigger Area for Billing Rule*

Charge Entry
Chart

What would you like the Billing Rule to do:*

Please specify any Additional Information required to create the Billing Rule (Items such as Providers, Insurances, Modifiers, DX codes, CPT Codes, Age restrictions, % of Increase/Decrease, etc)

THIS FORM NEEDS TO HAVE THE CONTACT AND SIGNATURE SECTION COMPLETED.

Please have the practice owner or practice administrator sign off on this form.

Authorized Name:*

Signature (by checking this box you are signing this document)*

Contact Person:*

Contact Email:*

Phone:* Ext:

Please attach official specifications if you have them (8MB max)
(.png,.jpg,.jpeg,.pdf,.xls,.xlsx,.doc,.docx,.tiff,.tif)