Welcome to the Visit Report. Simply provide the information required below and payment
can be made immediately via Paypal, or by first class mailed check. You can choose the
method.
1-800-717-9410
The total amount
of this bill
Members' name
Member ID Number
Member DOB
Date(s) of service
Office Visit Code
Office Visit Charges
CPT codes
Diagnosis Codes
 Charges
Briefly describe the reason for the visit
Briefly describe any refill medications,
as well as new or changed medications
Return Visit Scheduled?
If so, what date and time
Provider Information
Provider or Company Name or EHP
provider number, or NPI
Employer Identification Number (EIN)
Full address
Street, city, state, zipcode
If you want to be paid using
Paypal please provide your
Paypal email address here
If you want to be paid by mailed
check please provide the name
the check is payable to
Contact person
Contact person email address
Contact person phone number
File a Visit Report