Get Fort Wayne Std Clinic

This guide will help you navigate the process of completing the Fort Wayne Std Clinic form online. Following these clear instructions will ensure that you provide accurate information and understand the choices available to you.

Follow the steps to fill out your form accurately and efficiently.

1. Select the ‘Get Form’ button to access the online form and open it in your editor.
2. Enter the patient's name in the designated field. This field requires the full name of the person receiving the treatment.
3. Input the Medicare number (HICN) in the required field. Ensure that the number is correct to avoid any issues with billing.
4. Review the laboratory tests listed and note that you may have to pay if Medicare doesn’t cover the test. Fill in the specific test or tests where indicated.
5. Provide the reason why Medicare may not pay in the specified section. This is important information for determining your financial responsibility.
6. Input the estimated cost for the laboratory test, which is displayed in your documentation. Confirm this figure is accurate.
7. Read the options provided regarding the billing process carefully. Choose one option by checking the appropriate box, which indicates your decision.
8. If you have questions about the form or your options, reach out as instructed. You should ensure you understand the implications of your choice.
9. Sign in the designated signature area to confirm you have received and understood this notice.
10. Date the form as required to validate your submission.
11. Once completed, save your changes. You can download, print, or share the form as necessary.

Start filling out your form online to ensure timely processing.