Billing Information

For accurate billing reports, the client must furnish the information required on the requisition form. Patient’s full name and address; date of birth, and referring physician UPIN are the basic information necessary. Any questions regarding billing, please call our facility.

Bill Medicare – Check “Bill Medicare” on the test request

      1. Name and address of patient
      2. Medicare number/ Social Security number
      3. Date of birth
      4. ICD9 diagnosis code
      5. Referring physician’s UPIN
      6. Patient signature on the requisition, copy of Medicare card

Bill Medicaid – Check “Bill Medicaid” on the test request

      1. Name and address of patient
      2. Medicaid number/ Social Security number
      3. MediPass Number
      4. Date of birth
      5. ICD9 diagnosis code
      6. Referring physician’s UPIN
      7. Patient signature on the requisition, copy of Medicaid card

Bill Physician – Check “Bill Physician” on the test request

      1. Name of patient

Bill Patient – Check “Bill Patient” on the test request

      1. Name and address of patient
      2. Name of responsible party if other than patient.
      3. Telephone number of the patient.
      4. Social Security number

Bill Insurance

      1. Name and address of patient
      2. Name of responsible party if other than patient
      3. ID Number
      4. Group Number
      5. ICD9 diagnosis code
      6. Employer name
      7. Date of birth
      8. Copy of insurance card