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470 2486-2026
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- Click ‘Get Form’ to open the 470 2486 in the editor.
- Begin by entering the MEMBER INFORMATION. Fill in the STATE ID and MEMBER’S NAME (LAST, FIRST, MI) accurately.
- Next, provide PROVIDER INFORMATION. Enter the NPI PROVIDER NUMBER and complete the PROVIDER ADDRESS fields including STREET, CITY, STATE, and ZIP CODE.
- Indicate if there is OTHER INSURANCE by selecting YES or NO. If applicable, provide details about any OTHER INSURANCE DENIED.
- In the SERVICES section, list each service provided along with its PROCEDURE CODE, PLACE OF SERVICE, FIRST DATE, LAST DATE, UNITS, and TOTAL LINE CHARGE.
- Complete CLIENT PARTICIPATION AMOUNT and THIRD PARTY PAYMENT sections as necessary.
- Finally, ensure that both PROVIDER SIGNATURE and MEMBER/GUARDIAN SIGNATURE are included along with their respective dates.
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| Versions | Form popularity | Fillable & printable |
|---|---|---|
| 2008 | 4.9 Satisfied (496 Votes) |
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