Billing report form

Client name

1. Which Medical Billing Report would you like to order?

Standard Medical Billing Report

Custom Medical Billing Report

2. What should the Medical Billing Report be based on?

Past Medical Bills with Estimated Reimbursement

Future Costs Based on Life Care Plan

Both Past and Future

3. Select reimbursement method

Medicare

120% of the Medicare Rate

170% of the State Medicaid Rate

UCR 80th Percentile Allowed Amount

UCR 80th Percentile Charge Amount

When available, Negotiated Rates for Commercial Insurance

4. Select custom reimbursement method

Commercial Insurance Negotiated Rates

Client’s Actual Insurance Plan Rates

Other Custom Methodology

5. Would you like to include any report add-ons?

UCR analysis of Past Medical Bills

UCR analysis of Life Care Plan charge amounts

Rebuttal of Opposing Counsel’s Expert Witness Report

6. What insurance plan does the client have?

(Please provide the insurance company name and plan type. If none, enter N/A.)

Example: Blue Cross Blue Shield PPO, Aetna HMO, UnitedHealthcare Choice Plus

City

State

ZIP Code

Medical
Billing
request form