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Pennsylvania Health Care Cost Containment Council Request for Exception 225 Market Street Suite 400 Harrisburg PA 17101 Phone 717 232-8958 Fax 717 772-1401 Facility Name PAF Number Date Contact Person Title Address City State Zip Code Telephone Fax E-mail Request for UB04 Inpatient Data UB04 Ambulatory/Outpatient Data Laboratory Data Specific Data Element s Pertinent Quarter Note A separate form is required for each quarter Quarter Year Extens...
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Who needs phc4 paf form:
01
Individuals who have received healthcare services in Pennsylvania.
02
Patients who are seeking reimbursement for healthcare costs.
03
Healthcare providers who need to report patient information for research or statistical purposes.
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What is phc4 paf form?
The PHC4 PAF form is a Pennsylvania Health Care Cost Containment Council (PHC4) Patient and Financial form used to collect data on patient demographics and financial information.
Who is required to file phc4 paf form?
All hospitals and ambulatory surgical facilities in Pennsylvania are required to file the PHC4 PAF form.
How to fill out phc4 paf form?
The PHC4 PAF form can be filled out electronically or manually. Providers need to enter patient demographic information and details about the financial aspects of the patient's care, such as insurance coverage and charges.
What is the purpose of phc4 paf form?
The purpose of the PHC4 PAF form is to collect data on patient demographics and financial information in order to analyze healthcare costs and promote transparency in the healthcare system.
What information must be reported on phc4 paf form?
The PHC4 PAF form requires reporting of patient demographics (such as age, gender, race) and financial information (such as insurance coverage, charges, payment sources).
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