In Patient Medical claim generator

Service Type:

Fund Name:

Servicing Provider ID:

Facility ID:

Claim Type:

Fund Payee ID:

Invoice Number

Account Paid Indicator:

Claim Submission Authorised

IFC Indicator

Admission Date

Discharge Date

Compensation Indicator

Accident Indicator

First Name:

Last Name:

Gender:

DOB:

Medicare Number:

Medicare Sub Numerate:

Fund Membership Id:

UR Number:

Referral Provider Number:

Referral Date:

Referral Period:

Referral Period Type:

Referral Override Type:

Item Number:

Service Date:

Service Time:

Service Charge:

Service Text:

Duplicate Service:

LSP Number:

Multiple Procedures:

Self Deemed:

Equipment ID:

After Care Override Ind:

NumberOfPatientsSeen: