Dermatology Billing Reference Checklist
Complete this checklist to ensure all required information for dermatology billing is reviewed and accurate.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Provider Name
*
First Name
Last Name
Date of Service
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Diagnosis Code(s) (ICD-10)
*
Procedure Code(s) (CPT/HCPCS)
*
Insurance Provider
*
Medical Record Attached
*
Yes
No
Billing Checklist
*
Rows
Completed
Patient eligibility verified
1
Prior authorization obtained (if required)
2
Diagnosis and procedure codes reviewed
3
Documentation supports billed services
4
Insurance information confirmed
5
Co-pay/co-insurance collected (if applicable)
6
Claim form completed
7
Attachments included (if needed)
8
Additional Notes
Submit Checklist
Should be Empty: