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Page 1 of 3ISDH Hospital Service Report State Form 49476 (R /702) IC 16216Status: Finalized I. Hospital Information Hospital LIBRA HOSPITAL OF FORT WAYNE Name: Provider #: 152027 City: Fort Wayne
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01
To fill out provider 15-2027, follow these steps:
02
Start by entering the provider's name and contact information in the designated fields.
03
Provide the provider's identification number, such as their social security number or employer identification number.
04
Specify the type of provider and their specialty or area of expertise.
05
Fill in the details of the services provided by the provider, including the dates, duration, and any applicable codes.
06
If there are multiple services provided, list them separately and provide all relevant information for each.
07
Indicate the charges for each service and any applicable insurance or payment details.
08
Include any additional supporting documentation or attachments as required.
09
Review the completed form for accuracy and completeness before submitting it.
Who needs provider 15-2027?
01
Provider 15-2027 is required by medical facilities, such as hospitals, clinics, or private practices, that employ or contract with healthcare providers.
02
It is essential for maintaining accurate records of the services provided, billing purposes, and compliance with regulatory requirements.
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Insurance companies, government agencies, and auditors may also require provider 15-2027 as part of their evaluation and reimbursement processes.
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What is provider 15-2027?
Provider 15-2027 is a form used to report information about a service provider.
Who is required to file provider 15-2027?
Any service provider who meets certain criteria is required to file provider 15-2027.
How to fill out provider 15-2027?
Provider 15-2027 can be filled out online or by mail, following the instructions provided on the form.
What is the purpose of provider 15-2027?
The purpose of provider 15-2027 is to collect information about service providers for regulatory purposes.
What information must be reported on provider 15-2027?
Provider 15-2027 requires information such as contact details, services provided, and revenue generated.
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