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UNC OB Ultrasound Medicaid/Self Pay Authorization Form Name # of previous ultrasounds for this pregnancy DOB Fill out one related section completely MAN Incomplete forms will be returned and ultrasound

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What is ob ultrasound medicaidself pay?

Ob ultrasound medicaidself pay refers to the payment made for an obstetric ultrasound procedure by individuals who are covered by Medicaid or those who are self-paying without any insurance coverage.

Who is required to file ob ultrasound medicaidself pay?

Individuals who are covered by Medicaid or those who are self-paying without any insurance coverage are required to file ob ultrasound Medicaid self-pay.

How to fill out ob ultrasound medicaidself pay?

To fill out ob ultrasound Medicaid self-pay, you need to provide the necessary information related to the procedure, such as the patient's personal information, insurance details (if applicable), date and description of the procedure, healthcare provider information, and payment method.

What is the purpose of ob ultrasound medicaidself pay?

The purpose of ob ultrasound Medicaid self-pay is to ensure proper billing and payment for obstetric ultrasound procedures, particularly for individuals who are covered by Medicaid or those who do not have insurance coverage.

What information must be reported on ob ultrasound medicaidself pay?

The information that must be reported on ob ultrasound Medicaid self-pay includes the patient's personal information (name, address, contact details), insurance details (if applicable), date and description of the procedure, healthcare provider information, and payment method.

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