Requestor View | Red Zone

Request Form

Please complete the form below to request missing information or documentation related with a billing process.

Division:

Facility:

EVPS Account #:

Patient's Last Name:

Patient's First Name:

Date of Birth: DOB:

Patient Account #: PA #:

Medical Record #: MR #:

Date of Service: DOS:

Requesting:

Missing Item(s)

Notes

Attachment(s):

dummy_name_doc wdwdwd dwdw wdwq sss.zip

aaaa d dd d ddummy_name_doc.zip

dummy_name_doc.zip

Tickets Being Processed

Your assigned Site Billing Coordinator and Controller are handling your requests. See below all your open tickets in detail:

Ticket # Tckt. #

DS Submitted

Division | Facility | EVPS Account

Patient's Name

SBC

Cont

Details

Ticket #: 53918

Date Submitted: 12/7/2017

Division: Anesthesia
Facility: Aventura Baptist O/P Services
EVPS Account #: 011869701

Patient's Name: Guzman, Nuret

Site Billing Coordinator Actions:

Ticket Status:

Ticket #: 43915

Date Submitted: 7/26/2017

Division: Anesthesia
Facility: Baptist O/P Services - Country Walk
EVPS Account #: 011869701

Patient's Name: Gordon, Nicholas

Site Billing Coordinator Actions:

Ticket Status:

Closed Ticket History

Ticket # Tckt. #

DS Submitted

Division | Facility | EVPS Account

Patient's Name

ResolutionRes

Closed OnClsd