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HCFa-1513 Form: What You Should Know

Yes No LB7. Name. Address. Proprietary Institution Number. Form HCFA-1513 (5-86) Page 2 DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST (d) (To be completed by the CFA office) Chain Affiliate No. Yes No LB7. Name. Address. Provider Number. Form HCFA-1513 (5-86) Page 3 Disclosure of Ownership and Control Interest Statement. ADDRESS. PROVIDER NUMBER/CIA Number. Yes. No. LAB. 1513 (7/07) (e) (To be completed by the CFA office) Chain Affiliate No. Yes. No LB7. Name. Address. Provider Number. Form HCFA-1513 (5-86) Page 4 DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST. (f) (To be completed by the CFA office) Chain Affiliate No. Yes No LB7. Name. Address. Provider Number. Form HCFA-1513 (5-86) Page 5 DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST (F) (1) (To be completed by the CFA office) Chain Affiliate No. Yes. No LB7. Name. Address. Provider Number. Form HCFA-1513 (5-86) Page 6 (2) (To be completed by the CFA office) (a) (To be completed by the CFA office) Chain Affiliate No. Yes. No LB7. Name. Address. Provider Number. Form HCFA-1513 (5-86) Page 7 (b) (To be completed by the CFA office) Chain Affiliate No. Yes. No LB7. Name. Address. Provider Number. Form HCFA-1513 (5-86) Page 8 DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST (3) (To be completed by the CFA office) Chain Affiliate No. Yes. No LB7. Name. Address. Provider Number. Form HCFA-1513 (5-86) Page 9 (4) (To be completed by the CFA office) Chain Affiliate No. Yes. No LB7. Name. Address. Provider Number.

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Video instructions and help with filling out and completing HCFa-1513

Instructions and Help about HCFa-1513

Hi I'm Tommy with dr. Conover's office and I'm gonna take you through a hicfa we're gonna start over here with field number one if there is a spot that you can check which insurance company you have most of you will probably have a growth help group health plan you just check that and it come down here and fill out your information and it's all gonna be personalized this field right here is going to be the insured ID information and just follow the prompts down you're gonna need to go all the way down here to 13 and fill out all of these blocks it's going to be your personal information once you start here on 14 this is going to be accidental for information and and most likely this is not going to be something that's going to reference a patient of ours you're gonna come down here to field 24 you're gonna fill out your data service month/day/year format and it's most likely gonna be the same day your place of service is an 11 that's a code for office visit you're gonna have a CPT code we'll be able to prthat for you when you come in the office along with the charge this rendering provider ID is our tax identification number two zero four one five four five three zero and if you have several lines of service then you're gonna need to fill those out on each line as well if you have more than six will pryou with another HIPAA form and you'll come down here these are fields that will be available on our website in a PDF form so that they're already currently filled out you can see there's our tax identification number again exact accepting assignment you're gonna...

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