Here’s a form to get the ball rolling on new PBDs. It was developed by Melody Mulaik, president of Revenue Cycle Coding Strategies. Contact her at melody.mulaik@rccsinc.com.
Sample Request Form
Requestor Information | ||
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Name |
Title |
Request Submitted Date |
|
Phone | |
I attest that the Department Requirements Checklist has been completed and that I will submit the checklist with this request form. | ||
Service Location Information | ||
| ||
DBA Information | ||
Legal Name |
Proposed Opening Date | |
Physical Address | ||
City |
Zip | |
Provider and Hospital Information | ||
Affiliated Hospital |
Affiliated Hospital Tax ID# | |
Location |
|
If Off-Campus, how many miles from Affiliated Hospital? |
Services Provided per Location | |
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Services Provided
|
Will the services provided be a duplicate of an existing location?
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Additional Information: |