MEDICAL CLAIMS RESOURCE |
|
| Start Date______________________ | Company Name______________________ |
| Customer _____________________________________________________________ | |
| Street Address _________________________________________________________ | |
| Mailing Address ________________________________________________________ | |
| City/State/Zip __________________________________________________________ | |
| Phone Number _________________________________________________________ | |
| Contact Person _________________________________________________________ | |
| Type of bills - Health, Indemnity, Auto, W/C, Liability ____________________________ | |
| Thresholds: | |
| Physician _____________________________________________________________ | |
| Outpatient _____________________________________________________________ | |
| Inpatient _______________________________________________________________ | |
| Billing Information _______________________________________________________ | |
| Charge Per % of Savings __________________________________________________ | |
| Special Instructions | |
| ______________________________________________________________________ | |
| ______________________________________________________________________ | |
| ______________________________________________________________________ | |
| Signed___________________________ | Date___________________________ |