Provider Charges/Billing

Daily/Weekly Information to submit claims

Please correct the errors described below.

Provider Name

Attach File (ex.ins card, authorization)

Add file

Please upload a file

Date

Patient Name(Last, First)

* New Patient(*Doe, Jane)

CPT Procedure

Diagnosis Code

Telemedicine

Video Phone

Date

Patient Name(Last, First)

* New Patient(*Doe, Jane)

CPT Procedure

Diagnosis Code

Telemedicine

Video Phone

Date

Patient Name(Last, First)

* New Patient (*Doe, Jane)

CPT Procedure

Diagnosis Code

Telemedicine

Video Phone

Date

Patient Name(Last, First)

* New Patient (*Doe, Jane)

CPT Procedure

Diagnosis Code

Telemedicine

Video Phone

Date

Patient Name(Last, First)

* New Patient (*Doe, Jane)

CPT Procedure

Diagnosis Code

Telemedicine

Video Phone

Add Next Patient Information

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