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)