|
|
Please complete this Request for Payment , EquityHealth will process your payment
immediately upon receipt. This is not a claim, you will be paid regardless of the coding
sequence submitted, please be accurate with coding. All fields are required to be filled
out. If you do not know what to put in a box, please put "No Information Provided"
|
|
|
|
|
|
|
|
|
Member Number
|
|
|
|
|
|
|
Member DOB
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Date of Service
|
|
|
|
|
|
|
Provider EIN
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Your name:
|
|
|
|
|
|
|
Total Price
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Providers Name
|
|
|
|
|
|
|
Email:
|
|
|
|
|
|
|
|
|
|
|
|
|
|
MD/DO
|
|
|
|
DC
|
|
|
|
PA/NP
|
|
|
OTHER
|
|
|
|
|
DDS
|
|
|
|
|
|
|
|
|
|
Provider NPI#
or state license #
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Providers Address
|
|
|
|
|
|
|
|
|
City / State / Zip
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Phone Number
|
|
|
|
|
|
|
Fax Number
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Please list all ICD-9 codes that apply to this EH Member
|
|
|
Please List all the CPT codes that apply to this visit
|
|
|
|
|
|
|
|
|
|
|
|
|
Please provide a brief description of this visit, changes to medications, instructions for home care, referral
instructions, follow up care and appointments, and any other important data for this patient to remember. This
can be completed by anyone with the information requested.
|
|
|
|
|
|
|
|
Terms
The funds available to pay this invoice must be available in the members account at the time this invoice is
submitted or the payment will be rejected and you will have to bill the visit to the client directly. Providers are also
allowed to resubmit this invoice as many times as needed. Providers can also print and mail the invoice after
completing it and a mail payment will be sent in return. To verify funds, please call 1-800-717-9410, Monday through
Friday 9am to 5pm Eastern Time. You will need the ability to accept credit cards to receive immediate payments.
Payment at the time of service is through PayPal, you will need a PayPal account to recieve the payment, If you do not
have a PayPal account, we can mail a payment, there is a $5 deduction for this service.
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
I agree to the terms of this transaction
|
|
|
|
|
|
|
|
|
|
|
|
|
|
