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OFFICE POLICIES, ADVANCE BILLING NOTICE, AND CONSENT FORM Welcome to Medicare! We are pleased to have your family as members of our practice and look forward to participating in your child s health

How to fill out pedi-care advance billing notice

How to Fill Out Pedi-Care Advance Billing Notice:

1. Begin by gathering all the necessary information. This includes the child's name, date of birth, parent or guardian's contact information, and the services provided by the healthcare provider.
2. Fill in the child's name and date of birth in the appropriate fields on the form. Ensure that the information is accurate and matches the child's official records.
3. Provide the parent or guardian's contact information such as their name, address, phone number, and email address. This is important for any communication or clarification regarding the billing process.
4. Specify the services provided by the healthcare provider. This may include medical examinations, treatment procedures, prescribed medications, and any additional services rendered.
5. Include the dates of service for each specific service provided. This helps in determining the duration and frequency of the healthcare received.
6. Indicate the charges or fees for each service. Include the detailed costs, any applicable discounts, and the total amount due.
7. If there are any specific instructions or additional information that needs to be included, make sure to provide it in the appropriate section of the form.
8. Double-check all the filled-out information to ensure accuracy and completeness. Any errors or missing information may cause delays in the billing process.
9. Sign and date the pedi-care advance billing notice to acknowledge that the information provided is true and accurate.
10. Keep a copy of the filled-out form for your records and submit the original to the relevant billing department or healthcare provider.

Who Needs Pedi-Care Advance Billing Notice:

1. Parents or legal guardians of children who have received healthcare services from pedi-care providers.
2. Healthcare providers who offer medical care to children and require a detailed billing notice for reimbursement or insurance purposes.
3. Insurance companies or government agencies responsible for processing and approving claims for pediatric medical services.

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