MEDENT Allowed Amounts Request Form MEDENT Account Number:* Directory (if multiple directories): Fields To Be Updated (select at least 1):* Fee per Unit Allowed Amount Office Allowed Amount Facility Insurance Company(s) the Import is for (Please list Company Name(s) & Number(s) ):* Fee line(s) being updated:* What Column numbers in the file are being used for the import: Are the fee lines being updated setup by 'Dr, Speciality, Location:* Yes Update all fee lines Only update: No Do the fee lines use the date option* Yes Date(s) to update: No Attach File (if needed) (8MB max)(.png,.jpg,.jpeg,.pdf,.xls,.xlsx,.doc,.docx,.tiff,.tif) Additional Information/Setup: Authorized Name:* Signature (by checking this box you are signing this document)* Contact Person:* Contact Email:* Phone:* Ext:
