Check “Bill Client” on the test request form in the appropriate section. For client billing the following information is necessary:
3. Patient Date of Birth
4. Patient Sex
All other information is desired, but not required for this bill type. Client invoices are generated monthly.
Please mail payments to:
Seacliff Diagnostics Medical Group, Inc.
Attn: Billing Department
2100 Saturn Street, Suite 102
Monterey Park, CA 91755
BILL PATIENT
Check “Bill Patient” on the test request form in the appropriate section. Seacliff will bill the patient if complete billing information is provided on the test request form. Please advise the patient to expect a bill from Seacliff. For patient billing the following information is necessary:
1. Patient Name
2. Patient Age
3. Patient Date of Birth
4. Patient Sex
5. Patient Address
6. Patient phone number
BILL MEDI-CAL / MEDICAID
Check “Bill Medi-Cal” and provide the following required information:
1. Patient Name
2. Patient Age
3. Patient Date of Birth
4. Patient Sex
5. Patient Address
6. Patient Phone Number
7. Proof of current Medi-Cal eligibility in the form of a photocopy of the patient’s ID card, or presumptive eligibility identification.
8. ICD-9-CM diagnosis code(s) specific for the patient’s condition(s)
9. Referring Physician’s Name
10. Date of Issue (SOFP Patients)
BILL MEDICARE
Check “Bill Medicare” and provide the following required information:
1. Patient Name
2. Patient Age
3. Patient Date of Birth
4. Patient Sex
5. Patient Address
6. Patient Phone Number
7. Medicare Number (HIC#)
8. ICD-9-CM diagnosis code(s) specific for patient’s condition(s)
9. For testing not covered by Medicare, please have patient sign the new Advance
Beneficiary Notice (ABN) form acknowledging that the patient will be billed for required Medicare-uncovered services for which they are financially responsible. Referring Physician’s Name
NOTE: MEDICARE NOW REQUIRES ICD-9-CM DIAGNOSIS CODES FOR VIRTUALLY ALL LABORATORY PROCEDURES.
MEDICARE / MEDI-CAL COMBINED BILLING
This category applies to all patients who have a Medi-Cal number in which the aid number is between 10 and 20, or where the age of the patient is over 65, or, effective July 1, 1973 is totally disabled.
Check both “Bill Medicare” and “Bill Medi-Cal” on the request form and provide the following required information:
1. Patient Name
2. Patient Age
3. Patient Date of Birth
4. Patient Sex
5. Patient Address
6. Patient Phone Number
7. Medicare Number (HIC#)
5. Proof of eligibility in the form of a photocopy of the ID card.
6. ICD-9-CM diagnosis code(s) specific for patient’s condition(s)
7. Referring Physician’s Name
Patients will not be billed for testing not covered by Medicare or Medi-Cal.
NOTE: MEDICARE NOW REQUIRES ICD-9-CM DIAGNOSIS CODES FOR VIRTUALLY ALL LABORATORY PROCEDURES.
PRIVATE INSURANCE
Check “Insurance” on the request form and provide the following information:
1. Patient Name
2. Patient Address
3. Patient Date of Birth
4. Patient Sex
5. ICD-9-CM diagnosis code(s) specific for patient’s conditions(s)
6. Photocopy of insurance card including front and back.
7. Primary policy holder’s full name
8. Policy holder’s home telephone
9. Certificate number or Social Security Number of primary insured.
10. Relationship of patient to primary policy holder
11. Insurance Carrier Name
12. Insurance Carrier Address
13. Referring Physician’s Name
