SUPPLIER NAME: ____________________________________________________________________________________

PATIENT NAME ______________________________________________________________________________________

PATIENT ADDRESS ________________________________________________________________________________

CITY______________________________ ST._________ZIP_____________________________

DOES PATIENT HAVE OUT-OF-STATE ADDRESS? (Y) (N) IF SO:

ADDRESS________________________________________________________________________________

CITY______________________________ ST._________ ZIP_____________________________

DATE OF BIRTH: _____________ Sex__M__F__ HT.______WT._________SS#_________________________________

MEDICARE INFO:

MEDICARE NUMBER: _________________________________________________________________________________

DIAGNOSIS(S) OF PATIENT:___________________________________________________________________________

SECONDARY INSURANCE CO:

ADDRESS_____________________________________________________________________________

______________________________________________________________________________

CITY________________________ ST._________ ZIP________________________________

PHONE #: (______)______-________________________

POLICY NUMBER:_____________________________GROUP #:______________________________________________

Patient Paid Amount: $

DATE(S) OF SERVICE _________________________________ ACCEPT ASSIGNMENT (Y/N)____________________

ITEM CODE(or description)______________________________________NO. OF UNITS_________PRICE___________

ITEM CODE(or description)______________________________________NO. OF UNITS_________PRICE___________

ITEM CODE(or description)______________________________________NO. OF UNITS_________PRICE___________

ITEM CODE(or description)______________________________________NO. OF UNITS_________PRICE___________

DO YOU WANT THESE ITEM(S) BILLED AUTOMATICALLY EVERY 30 DAYS?______Y / N

PATIENT'S PHYSICIAN NAME:_____________________________________________________________________________

PHYSICIAN ADDRESS:_________________________________________________________________________

______________________________________________________________________

CITY____________________ ST.__________ ZIP___________________________

PHONE #: (_______)_______-____________________________

UPIN #:_______________________________________