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How to use or fill out the direct billing form
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Click ‘Get Form’ to open the direct billing application in our editor.
Begin by filling out the ACCOUNT INFORMATION section. Enter your COMPANY NAME, TITLE, and CONTACT details including PHONE # and E-MAIL ADDRESS. Ensure all fields are completed accurately.
Next, provide your BILLING ADDRESS along with the corresponding STATE, CITY, and ZIP code. Include any specific DEPT and ATTN NAME if applicable.
In the CREDIT CARD INFORMATION section, select your card type (AMEX, VISA, MASTERCARD, DISCOVER) and fill in the CARDHOLDER’S NAME, CARD NUMBER, SECURITY CODE, and EXPIRATION DATE. Don’t forget to sign where indicated.
Complete the CREDIT REFERENCES section by listing companies you have credit with. Include their CONTACT PERSONS, ADDRESSES, CITIES, STATES, and PHONE #s.
Fill out BANK REFERENCES with your bank's name and account number along with a contact person’s details.
Finally, review the certification statement at the bottom of the form. Sign it as AUTHORIZED SIGNATURE and print your name along with the DATE and TITLE before submitting.
Start using our platform today to fill out your direct billing form for free!
For example, most banks offer online bill payment where you go to your online bank account and direct the bank to pay certain bills. This is a manual process that you have to complete each month.
What is an example of a direct payment?
What are the types of billing processes? There are three types of billing methods: time-based, usage-based, and feature-based. Time-based billing is the most common type, where the customer is billed based on the duration of the service.
What is an example of direct billing?
Service-based organizations that provide ongoing work, such as monthly consulting work, might use direct billing so invoices are emailed to clients automatically. In healthcare, a clinic might choose to bill patients directly rather than involve insurers.
What is an example of a direct bill payment method?
Examples of a Direct payment Josie lives independently in her own home but following a fall needs help with day to day living at home. A direct payment means that she can employ a personal assistant (PA) to help her to wash, dress, shop for groceries and prepare meals.
What is a CMS-1500 billing form?
Direct Billing is an arrangement whereby guest charges are transferred to an Accounts Receivable account for payment. Typically, when a guest uses direct billing, an invoice is sent directly to the guests company or other sponsoring organization.
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Clinic providers must use the HIPAA 837 Institutional (837I) transaction. Direct billers should refer to the sources listed below in order to comply with the
Legal Name of Organization: Billing Address: City: State: Zip: Group Contact: Telephone Number: Accounting Contact: Telephone Number: Main Phone Number:.
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