MEDICAID/ARKIDS A/ARKIDS B
|
Name of Patient as it would appear on Medicaid card: ______________________________________ |
Date of Birth of Patient ________________________ |
|
SS# of Pt (if available): ________________________ |
|
|
Name of Guardian: _______________________________________ |
Guardian’s date of birth: ________________________ |
|
Guardian’s SS#: ________________________ |
If we have not received a Medicaid card, Medicaid number, or had some kind of communication between you and our office explaining why you don’t have the card within 30 days of the visit you will be turned over to collections.
To ensure that our office will receive the Medicaid card or number in the amount of time needed to file we will need the following:
A copy of a major credit card
A driver’s license
If neither of the above can be provided the Guardian will be responsible for the amount due on the Date of Service before ever being seen by the Doctor.
________________________________________________________________________
Credit Card type: __Visa __MC __Discover __AMEX
Credit Card #: ___________________________ Exp Date:_____________________
Name of Cardholder_______________________________________________________