Optometry Coding & Billing Alert

Take two copies of this contract on every SNF visit - one to keep for billing records and one for the SNF. Be sure an SNF administrator signs the contract.

Date:

I am Dr.                                            . Occasionally I may be providing services to patients in your skilled nursing facility. My protocol is [insert brief clinical protocol written by doctor here]. I will then bill your facility for the services provided at your request. Payment will be expected regardless of your facility's reimbursement status with Medicare.

Payment should be cut and sent to the address below within X number of days from receiving my bill.

Provider tax ID number:

Please send payment to:
Billing Office Address
City, State, ZIP code

Signed:

Dr.                             , SNF administrator:

    - Provided by Joan Elfeld, CPC, president of Denver-based Medical Practice Support Services Inc.