medi-processing.com- Existing Patient Billing

EXISTING PATIENT BILLING SHEET
EXISTING PATIENT BILLING SHEET
Office - (954)344-7718
NAME OF DOCTOR

Rows	PATIENT NAME	DX	DOS	$	CPT	Place of Service	Auth#
1
2
3
4
5
6
7
8
9
10

Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Medi-Processing Services, Inc
Electronic Claims Processing Specialists
Should be Empty: