Patient Form

General Information

Office Name(Required)

Patient Name(Required)

Please enter the patient’s first name first and the last name last

Patient Street Address(Required)

Patient City(Required)

Patient State(Required)

Patient Zip Code(Required)

Patient Date of Birth(Required)

Use the date picker OR enter in the format mm/dd/yyyy

Patient SSN

Patient Sex(Required)

Patient Email Address

This field is to be completed only by providers enrolled for BillFlash electronic patient statements.

Primary Insurance Information

Insurance Company Name(Required)

EDI Payer Number

If shown on the back of the patient’s insurance card, please provide the payer’s EDI Payer Number

Policy ID or Claim #(Required)

Please enter the patient’s ID # as it appears on the patient’s insurance card OR provide the claim # for auto and work comp claims

Group Number

Please provide the Group Number that appears on the patient’s health insurance card

Is the Patient the Insured?(Required)

Yes

Insured Name(Required)

Insured Date of Birth(Required)

Please provide the date of birth of the insured (NOT the patient). Use the date picker OR enter in the format mm/dd/yyyy

Is Condition Related To:(Required)

None

Auto

Employment

Other

If Related to an Accident, Date of Accident(Required)

Use the date picker OR enter in the format mm/dd/yyyy

Claims Office Mailing Address(Required)

If related to an accident, please provide the mailing address where the adjuster has indicated claims are to be sent

Street Address City State ZIP Code

Claims Office Phone Number(Required)

Claims Office Fax Number(Required)

For accident claims you must provide the claims office fax number for the payer. If you do not have this please contact the adjuster to obtain it prior to completing this form.

Adjuster Name(Required)

Secondary Insurance Information

Does the patient have secondary insurance?(Required)

Yes

Secondary Insurance Company Name(Required)

Secondary Insurance Company Phone

Secondary Insurance Company Address

Secondary Insurance ID #(Required)

Secondary Insurance Group #

Secondary Insured Name(Required)

Secondary Insured Date of Birth(Required)

Use the date picker OR enter in the format mm/dd/yyyy

If Seen in a Hospital or Nursing Facility

Name of Facility

Date of Admission(Required)

Use the date picker OR enter in the format mm/dd/yyyy

Referring Provider Information

Name of Referring Provider

Referring Provider NPI(Required)

Diagnosis Codes

Please enter a maximum of 4 diagnosis codes(Required)

Insurance Verification

Do you want MBPros to verify eligibility and benefits?(Required)

For providers enrolled for our PremiumPlus or Premium Service, a fee of $7.95 applies per verification. For Platinum Service providers, there is no fee if you do not exceed 60 verifications per billing month.

Yes

Additional Information

Additional Information Needed