Get Change Request 5850 - Cms

This guide provides a detailed overview of the Change Request 5850 - Cms, outlining the necessary steps to effectively fill out the online form. By following these instructions, users can ensure compliance and accuracy in their submissions.

Follow the steps to complete the Change Request 5850 - Cms form online.

1. Press the ‘Get Form’ button to download the Change Request 5850 - Cms form and access it in an editor.
2. Enter your provider name, address, and telephone number in the designated fields. Ensure you use the minimum required information: name, city, state, and ZIP code. It is acceptable to include a post office box number or street address.
3. Input the patient control number, which is a unique number assigned by the provider for tracking patient records.
4. Specify the medical/health record number if applicable. This is not mandatory but can assist in retrieving patient information.
5. Select the type of bill using the appropriate four-digit alphanumeric code that indicates the facility type, care classification, and bill sequence. Follow the instructions provided for proper coding.
6. Complete the necessary federal tax number and statement covers period fields, ensuring the correct format for these entries.
7. Provide patient demographics, including the patient’s name, address, date of birth, and sex, following the specified requirements.
8. Fill out the admission date for inpatient and home health claims, ensuring it matches the date of service provided.
9. Enter additional required information, such as type of admission/visit, point of origin for admission/visit, and diagnosis codes as necessary.
10. Review your entries thoroughly for accuracy. Once you have filled out all required fields correctly, you can save the changes, download, print, or share the form as needed.

Get started on completing your Change Request 5850 - Cms form online today!