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