BMI Billing Form

Examiner Name:

Examiner Social Security Number:

Order Date:

Insurance Company Name and Code:

City, State:

Agent Name and Code:

Agency Name and Code:

Applicant Name:

Applicant Home Address:

City, State, Zip:

Applicant Date of Birth:

Applicant Social Security Number:

Amount of Insurance:

Policy Number:

Type of Insurance   Procedures Performed
Life

Health

Disability

Long Term Care

Other

  Paramed

Blood

Urine

EKG

Saliva

 Finger Stick

MD Exam

MD Exam w/ Treadmill

Amplified/Vitals

Lab Name:                                                         Billing Company: (from labslip)          
Bar Code:                                                           Completed Date :      
         


Comments:

PLEASE PRINT AND REVIEW BEFORE SUBMITTING!