Interventional Radiology Billing Intake Form
Please complete all required fields to facilitate interventional radiology billing intake. Do not include sensitive identifiers or full financial account numbers.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Billing Contact Name
*
First Name
Last Name
Billing Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Billing Contact Email
example@example.com
Date of Service
*
-
Month
-
Day
Year
Date
Procedure Type
*
Please Select
Angiography
Embolization
Venous Access
Biopsy
Ablation
Other
Insurance Provider
*
Please Select
Aetna
Blue Cross Blue Shield
Cigna
Medicare
Medicaid
UnitedHealthcare
Other
Insurance Member ID (do not include SSN or full account number)
Authorization or Pre-Certification Number
Last 4 digits of payment card (if applicable)
Billing Notes or Special Instructions
Submit Billing Intake
Should be Empty: