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ThirdParty Billing Authorization for Payment Student Information Name (Last, First, Middle Initial)WMD ID Number (WIN)ThirdPartyNameAddressCity, State, Zip Telephone NumberContact Personal AddressSemester
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How to fill out third-party billing authorization for

01
Obtain the third-party billing authorization form from the appropriate source.
02
Fill out the patient's information, including their name, date of birth, and insurance information.
03
Provide the name and contact information of the third-party responsible for billing.
04
Include the services or items that the third-party will be responsible for paying for.
05
Sign and date the form, and make a copy for your records.
06
Submit the completed form to the appropriate party for processing.

Who needs third-party billing authorization for?

01
Individuals who are receiving medical services or items that will be paid for by a third-party.
02
Healthcare providers or facilities who need to bill a third-party for services rendered to a patient.
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Third-party billing authorization is used to allow a third party to be billed for services or products provided to a specific individual.
Any individual or entity who wishes to have a third party billed for services or products must file third-party billing authorization.
To fill out third-party billing authorization, the individual or entity must provide information about the third party, details of the services or products provided, and any other relevant details.
The purpose of third-party billing authorization is to streamline the payment process and ensure that the correct party is billed for the services or products provided.
Information that must be reported on third-party billing authorization includes details of the third party, the services or products provided, and any other relevant information.
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