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12. Patient’s or Authorized Person’s Signature
Type "none" in this box if you do not want "signature on file" in this box.
13. Insured’s or Authorized Person’s Signature
Type "none" in this box if you do not want "signature on file" in this box.
17a. The Other ID number of the referring, ordering, or supervising provider
Should look something like "1C 123456789"
17b. NPI#
NPI#
24i. ID Qualifier
Should look something like "1C"
24j-top line. Other ID# of the rendering provider
Should look something like "123456789" (after the "1C"). Report the Identification Number in Items 24I and 24J only when different from data recorded in items 33a and 33b.
24j-bottom line. Rendering Provider ID #
NPI number (ie. 1234567890). Report the Identification Number in Items 24I and 24J only when different from data recorded in items 33a and 33b.
25. Federal Tax ID Number
Federal Tax ID Number
Do not enter hyphens with numbers.
25. Checkbox SSN or EIN for Federal Tax ID Number
SSN or EIN?
32. Service Facility Location Information
1st Line – Name
2nd Line – Address
3rd Line – City, State and Zip Code
Do not use commas, periods, or other punctuation in the address. When entering a 9 digit zip code, include the hyphen. To separate lines, please type a hyphen, which won't be printed.
32a. NPI number.
Enter the NPI number of the service facility location in 32.
32b. Other ID#
Enter the two digit qualifier identifying the non-NPI number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number.
33. Billing Provider Info & Ph #.
Enter the provider’s or supplier’s billing name, address, zip code, and phone number. Enter the name and address information in
the following format:
1st Line – Name
2nd Line – Address
3rd Line – City, State and Zip Code
Do not use commas, periods, or other punctuation in the address. Enter a space between town name and state code; do not include a comma.
When entering a 9 digit zip code, include the hyphen. Do not use a hyphen or space as a separator within the telephone number. To separate lines, please type a hyphen, which won't be printed.
33a. NPI#
Enter the NPI number of the billing provider in 33.
33b. Other ID#
Enter the two digit qualifier identifying the non-NPI number followed by the ID number. Do not enter a space, hyphen, or other separator between the qualifier and number.
Other printing instructions, ie. checkmark line 1-Medicare
Type in printing instructions, ie. checkmark line 1 "Medicare".
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