BILLING QUESTION

Date: 

 

Who filled out this form?

Select: First Name: Last Name: 

 

Patient Information

First Name: Last Name: 
DOB: Greenway ID: 

Address:

 

Has Email?  YES  NO 
Home Phone?  YES  NO 
Work Phone?  YES  NO 
Cell Phone?  YES  NO 

 

Primary Insurance Name: ID#: 

Secondary Insurance?  YES  NO 

Tertiary Insurance?  YES  NO 

Has patient spoken to the Billing Staff previously?  YES  NO 

Is there an Invoice number?  YES  NO 

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