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*




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:*

*

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)