Billing Form

Office Name(Required)

Are All Visits Below Conducted by Telehealth?(Required)

If all visits conducted on this billing log were done by telehealth and all patients on this form were at home at the time of the telehealth session, enter Yes.

If some of the visits were done by telehealth OR at least one patient listed was not at home for the telehealth session, enter No.
Then enter (10) after the last procedure code for each patient where telehealth was performed and the patient was at home. Enter (02) after the last procedure code for each patient where telehealth was performed and the patient was not at home.

If no visits on the billing log were done by telehealth, just select No.

Yes

Patient Number 1

Patient Name(Required)

Enter the patient’s first name first and the patient’s last name last. Enter the patient’s name as it appears on his/her insurance card. Do NOT use nicknames.

Date of Service(Required)

MM slash DD slash YYYY

Procedure Codes(Required)

Copay Type

If the patient paid a copayment, select below the method of copayment paid.

Cash

Check

Credit Card

None

Copay Paid(Required)

Check Number(Required)

New Diagnosis Codes (max 4)

If the diagnosis codes have changed for the patient since the last visit, enter the new diagnosis codes in this section. If the diagnosis codes have NOT changed, leave this field BLANK.

Patient Number 2

Patient Name

Enter the patient’s first name first and the patient’s last name last. Enter the patient’s name as it appears on his/her insurance card. Do NOT use nicknames.

Date of Service(Required)

MM slash DD slash YYYY

Procedure Codes(Required)

Copay Type

If the patient paid a copayment, select below the method of copayment paid.

Cash

Check

Credit Card

None

Copay Paid(Required)

Check Number(Required)

New Diagnosis Codes (max 4)

If the diagnosis codes have changed for the patient since the last visit, enter the new diagnosis codes in this section. If the diagnosis codes have NOT changed, leave this field BLANK.

Patient Number 3

Patient Name

Enter the patient’s first name first and the patient’s last name last. Enter the patient’s name as it appears on his/her insurance card. Do NOT use nicknames.

Date of Service(Required)

MM slash DD slash YYYY

Procedure Codes(Required)

Copay Type

If the patient paid a copayment, select below the method of copayment paid.

Cash

Check

Credit Card

None

Copay Paid(Required)

Check Number(Required)

New Diagnosis Codes (max 4)

If the diagnosis codes have changed for the patient since the last visit, enter the new diagnosis codes in this section. If the diagnosis codes have NOT changed, leave this field BLANK.

Patient Number 4

Patient Name

Enter the patient’s first name first and the patient’s last name last. Enter the patient’s name as it appears on his/her insurance card. Do NOT use nicknames.

Date of Service(Required)

MM slash DD slash YYYY

Procedure Codes(Required)

Copay Type

If the patient paid a copayment, select below the method of copayment paid.

Cash

Check

Credit Card

None

Copay Paid(Required)

Check Number(Required)

New Diagnosis Codes (max 4)

If the diagnosis codes have changed for the patient since the last visit, enter the new diagnosis codes in this section. If the diagnosis codes have NOT changed, leave this field BLANK.

Patient Number 5

Patient Name

Enter the patient’s first name first and the patient’s last name last. Enter the patient’s name as it appears on his/her insurance card. Do NOT use nicknames.

Date of Service(Required)

MM slash DD slash YYYY

Procedure Codes(Required)

Copay Type

If the patient paid a copayment, select below the method of copayment paid.

Cash

Check

Credit Card

None

Copay Paid(Required)

Check Number(Required)

New Diagnosis Codes (max 4)

If the diagnosis codes have changed for the patient since the last visit, enter the new diagnosis codes in this section. If the diagnosis codes have NOT changed, leave this field BLANK.

Patient Number 6

Patient Name

Enter the patient’s first name first and the patient’s last name last. Enter the patient’s name as it appears on his/her insurance card. Do NOT use nicknames.

Date of Service(Required)

MM slash DD slash YYYY

Procedure Codes(Required)

Copay Type

If the patient paid a copayment, select below the method of copayment paid.

Cash

Check

Credit Card

None

Copay Paid(Required)

Check Number(Required)

New Diagnosis Codes (max 4)

If the diagnosis codes have changed for the patient since the last visit, enter the new diagnosis codes in this section. If the diagnosis codes have NOT changed, leave this field BLANK.

Patient Number 7

Patient Name

Enter the patient’s first name first and the patient’s last name last. Enter the patient’s name as it appears on his/her insurance card. Do NOT use nicknames.

Date of Service(Required)

MM slash DD slash YYYY

Procedure Codes(Required)

Copay Type

If the patient paid a copayment, select below the method of copayment paid.

Cash

Check

Credit Card

None

Copay Paid(Required)

Check Number(Required)

New Diagnosis Codes (max 4)

If the diagnosis codes have changed for the patient since the last visit, enter the new diagnosis codes in this section. If the diagnosis codes have NOT changed, leave this field BLANK.

Patient Number 8

Patient Name

Enter the patient’s first name first and the patient’s last name last. Enter the patient’s name as it appears on his/her insurance card. Do NOT use nicknames.

Date of Service(Required)

MM slash DD slash YYYY

Procedure Codes(Required)

Copay Type

If the patient paid a copayment, select below the method of copayment paid.

Cash

Check

Credit Card

None

Copay Paid(Required)

Check Number(Required)

New Diagnosis Codes (max 4)

If the diagnosis codes have changed for the patient since the last visit, enter the new diagnosis codes in this section. If the diagnosis codes have NOT changed, leave this field BLANK.

Patient Number 9

Patient Name

Enter the patient’s first name first and the patient’s last name last. Enter the patient’s name as it appears on his/her insurance card. Do NOT use nicknames.

Date of Service(Required)

MM slash DD slash YYYY

Procedure Codes(Required)

Copay Type

If the patient paid a copayment, select below the method of copayment paid.

Cash

Check

Credit Card

None

Copay Paid(Required)

Check Number(Required)

New Diagnosis Codes (max 4)

If the diagnosis codes have changed for the patient since the last visit, enter the new diagnosis codes in this section. If the diagnosis codes have NOT changed, leave this field BLANK.

Patient Number 10

Patient Name

Enter the patient’s first name first and the patient’s last name last. Enter the patient’s name as it appears on his/her insurance card. Do NOT use nicknames.

Date of Service(Required)

MM slash DD slash YYYY

Procedure Codes(Required)

Copay Type

If the patient paid a copayment, select below the method of copayment paid.

Cash

Check

Credit Card

None

Copay Paid(Required)

Check Number(Required)

New Diagnosis Codes (max 4)

If the diagnosis codes have changed for the patient since the last visit, enter the new diagnosis codes in this section. If the diagnosis codes have NOT changed, leave this field BLANK.

Patient Number 11

Patient Name

Enter the patient’s first name first and the patient’s last name last. Enter the patient’s name as it appears on his/her insurance card. Do NOT use nicknames.

Date of Service(Required)

MM slash DD slash YYYY

Procedure Codes(Required)

Copay Type

If the patient paid a copayment, select below the method of copayment paid.

Cash

Check

Credit Card

None

Copay Paid(Required)

Check Number(Required)

New Diagnosis Codes (max 4)

If the diagnosis codes have changed for the patient since the last visit, enter the new diagnosis codes in this section. If the diagnosis codes have NOT changed, leave this field BLANK.

Patient Number 12

Patient Name

Enter the patient’s first name first and the patient’s last name last. Enter the patient’s name as it appears on his/her insurance card. Do NOT use nicknames.

Date of Service(Required)

MM slash DD slash YYYY

Procedure Codes(Required)

Copay Type

If the patient paid a copayment, select below the method of copayment paid.

Cash

Check

Credit Card

None

Copay Paid(Required)

Check Number(Required)

New Diagnosis Codes (max 4)

If the diagnosis codes have changed for the patient since the last visit, enter the new diagnosis codes in this section. If the diagnosis codes have NOT changed, leave this field BLANK.

Patient Number 13

Patient Name

Enter the patient’s first name first and the patient’s last name last. Enter the patient’s name as it appears on his/her insurance card. Do NOT use nicknames.

Date of Service(Required)

MM slash DD slash YYYY

Procedure Codes(Required)

Copay Type

If the patient paid a copayment, select below the method of copayment paid.

Cash

Check

Credit Card

None

Copay Paid(Required)

Check Number(Required)

New Diagnosis Codes (max 4)

If the diagnosis codes have changed for the patient since the last visit, enter the new diagnosis codes in this section. If the diagnosis codes have NOT changed, leave this field BLANK.

Patient Number 14

Patient Name

Enter the patient’s first name first and the patient’s last name last. Enter the patient’s name as it appears on his/her insurance card. Do NOT use nicknames.

Date of Service(Required)

MM slash DD slash YYYY

Procedure Codes(Required)

Copay Type

If the patient paid a copayment, select below the method of copayment paid.

Cash

Check

Credit Card

None

Copay Paid(Required)

Check Number(Required)

New Diagnosis Codes (max 4)

If the diagnosis codes have changed for the patient since the last visit, enter the new diagnosis codes in this section. If the diagnosis codes have NOT changed, leave this field BLANK.

Patient Number 15

Patient Name

Enter the patient’s first name first and the patient’s last name last. Enter the patient’s name as it appears on his/her insurance card. Do NOT use nicknames.

Date of Service(Required)

MM slash DD slash YYYY

Procedure Codes(Required)

Copay Type

If the patient paid a copayment, select below the method of copayment paid.

Cash

Check

Credit Card

None

Copay Paid(Required)

Check Number(Required)

New Diagnosis Codes (max 4)

If the diagnosis codes have changed for the patient since the last visit, enter the new diagnosis codes in this section. If the diagnosis codes have NOT changed, leave this field BLANK.

Billing Form

Patient Number 1

Patient Number 2

Patient Number 3

Patient Number 4

Patient Number 5

Patient Number 6

Patient Number 7

Patient Number 8

Patient Number 9

Patient Number 10

Patient Number 11

Patient Number 12

Patient Number 13

Patient Number 14

Patient Number 15

Additional Comments