Full Medical Bill Audit Intake Form
Securely enroll for a comprehensive medical bill review by OHH Health Solutions. Please complete all sections and upload required documents.
SECTION 1: CLIENT & PATIENT INFORMATION
Provide details about yourself and the patient (if different).
Full Name of Person Completing This Form
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address (primary communication & delivery of audit results)
*
example@example.com
Are you the patient listed on the bill?
*
Yes
No
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
Date
Relationship to Patient
*
Please Select
Spouse
Parent/Guardian
Child
Other Family Member
Other (please specify)
SECTION 2: BILLING & FINANCIAL RESPONSIBILITY
Clarify who is responsible and who should receive updates.
Who is financially responsible for this account?
*
Patient
Family Member
Other (please specify)
Who should OHH contact with updates regarding this audit?
*
Person completing this form
Another authorized individual
Authorized Contact Full Name
*
First Name
Last Name
Authorized Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Authorized Contact Email Address
*
example@example.com
SECTION 3: BILL OVERVIEW
Details about the medical bill to be audited.
Provider / Hospital Name
*
Type of Facility
*
Hospital (Inpatient)
Hospital (Outpatient)
Emergency Department
Surgery Center
Other
Date(s) of Service
*
Total Amount Billed (USD)
*
Current Balance Claimed by Provider (USD)
*
Has this bill been:
*
Paid
Partially Paid
Sent to Collections
Under Payment Plan
Not Sure
SECTION 4: INSURANCE INFORMATION
Provide insurance details relevant to this bill.
Insurance Type
*
Medicare
Medicaid
Medicare Advantage
Private Insurance
Uninsured / Self-Pay
Insurance Company Name
*
Member ID
*
Group Number (if applicable)
Upload Insurance Card (front & back)
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
SECTION 5: DOCUMENT UPLOADS (REQUIRED)
Upload all documents related to this bill. Multiple files may be submitted.
Upload Medical Bill(s) / Itemized Statement
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Upload Explanation of Benefits (EOBs)
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Upload Hospital Account Summary or Patient Statement
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Upload any prior appeal letters or correspondence (optional)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Please include all statements and supporting documents related to this episode of care. Multiple documents may be uploaded.
SECTION 6: BILLING HISTORY & CONTEXT
Help us understand prior actions and communications.
Have you previously contacted the provider or insurance about this bill?
*
Yes
No
If yes, briefly describe the outcome
Are you receiving repeated or confusing bills for the same services?
*
Yes
No
SECTION 7: SERVICE SCOPE & DELIVERABLES
Understand what is included and not included in this service.
What This Full Medical Bill Audit Includes:
• Line-by-line charge review
• Coding and insurance processing verification
• Identification of duplicate, incorrect, or unbundled charges
• Written Billing Correction Plan outlining findings and next steps
• A family-friendly call script to use when contacting the provider or insurer
What This Service Does Not Include:
• Direct phone calls to providers or insurers on your behalf
• Appeals, disputes, or negotiations unless separately contracted
• Guarantees of billing corrections or balance reductions
I understand this is a comprehensive audit, not a guarantee of correction.
*
I understand this is a comprehensive audit, not a guarantee of correction
I understand OHH does not contact providers or insurers as part of this service.
*
I understand OHH does not contact providers or insurers as part of this service
I understand additional advocacy services may require a separate agreement.
*
I understand additional advocacy services may require a separate agreement
SECTION 8: TURNAROUND TIME & DELIVERY
Estimated completion and delivery details.
Estimated Turnaround Time:
Full audits are typically completed within X–X business days after all required documents are received.
Results will be delivered electronically in a written report format.
I understand the estimated turnaround time and delivery method.
*
I understand the estimated turnaround time and delivery method
SECTION 9: AUTHORIZATION & ELECTRONIC SIGNATURE
Authorize OHH to review the provided documents.
Electronic Signature of Client or Authorized Representative
*
Date
*
 -
Month
 -
Day
Year
Date
Submit Enrollment Form
Submit Enrollment Form
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