New Billing Rule Form

New Billing Rule Request Form

New Billing Rule Request Form

Please fill out all required sections on this form and submit

Support will review your request and followup with your office to assist in creating the rule.

MEDENT Account Number:*

Directory (if multiple directories):

Trigger Area for Billing Rule*

Charge Entry
Chart

What would you like the Billing Rule to do:*

Please specify any Additional Information required to create the Billing Rule (Items such as Providers, Insurances, Modifiers, DX codes, CPT Codes, Age restrictions, % of Increase/Decrease, etc)

THIS FORM NEEDS TO HAVE THE CONTACT AND SIGNATURE SECTION COMPLETED.

Please have the practice owner or practice administrator sign off on this form.

Authorized Name:*

Signature (by checking this box you are signing this document)*

Contact Person:*

Contact Email:*

Phone:* Ext:

Please attach official specifications if you have them (8MB max)
(.png,.jpg,.jpeg,.pdf,.xls,.xlsx,.doc,.docx,.tiff,.tif)