AGENCY: Department of Health and Human Services. Office of Children with Special Healthcare Needs

SERIES: 7807
TITLE: Insurance billing forms
DATES: 1982-
ARRANGEMENT: Alphanumerical

DESCRIPTION: These are copies of invoices, used as a suspense file, sent to the patient's insurance company, third party payers or to the patient himself for those patients who are capable of paying for all or part of the cost of treatment. The form includes the patients name, address, date of birth, and telephone number, the patient's chart number, the name and address of a responsible party other than the patient, the name and address of the insurance company, the insurance policy number, the name and address of the responsible party's employer, the signature of the patient or patient's parent, the date of service, the type of treatment given and the charge for the treatment, the total due, the name of the health care provider(s), the diagnosis, the invoice number, the date of billing, and the authorized signature for the division.

RETENTION

Retain until resolution of issue

DISPOSITION

Destroy.

RETENTION AND DISPOSITION AUTHORIZATION

These records are in Archives' permanent custody.

APPROVED: 08/1986

FORMAT MANAGEMENT

Paper: Retain in Office until the bill is paid or written off and then destroy.

APPRAISAL

Administrative Fiscal

This copy of the form is used as a suspense file to ensure that the bill is paid. When payment is received, the billing form is removed from the file to be destroyed. The record copy of this form is part of the patient chart.

PRIMARY DESIGNATION

Private

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