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Get Sentara Healthcare Additional Information Request 2005-2026
How it works
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Open form follow the instructions
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Easily sign the form with your finger
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Send filled & signed form or save
How to fill out the Sentara Healthcare Additional Information Request online
This guide is designed to assist users in completing the Sentara Healthcare Additional Information Request form online. By following these instructions, you will be able to accurately submit the necessary information needed for your medical billing inquiries.
Follow the steps to complete the request form successfully.
- Press the ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by entering your client number in the designated field at the top of the form.
- Next, fill in the statement date, which is the date when you received the bill.
- If applicable, indicate whether charges should be billed to the patient, Medicare, Medicaid, or another insurance provider. Include this information in the relevant section.
- Provide the patient's personal details including their social security number, name, date of service, and address (street, city, state, zip code). Make sure all information is accurate.
- Fill in the patient's date of birth, diagnosis or ICD-9 code, sex, and name of the ordering physician.
- Include the Medicare ID number and the insurance carrier name if applicable.
- If there are other insurances involved, enter the Medicaid ID number, the relevant state, group number, and identification number.
- Specify the effective date of the insurance coverage, providing both the start and end dates.
- Fill in the insurance carrier's address and the employer's name, if relevant.
- If the subscriber is different from the patient, complete the section with subscriber's name and their relationship to the patient.
- For Champus information, fill in the sponsor’s name, sponsor's SSN, their rank, and branch.
- Finalize the form by obtaining the required signature from the physician or their designee, and include their phone number.
- Once the form is completed and reviewed for accuracy, users can save changes, download, print, or share the form as needed.
Complete your forms online today to ensure your requests are addressed promptly.
Medical information means any individually identifiable information, in electronic or physical form, regarding the individual's medical history or medical treatment or diagnosis by a health care professional.