• Name and Address of Payor *
• Toll Free Number for Payor *
• Subscriber's Name/Address *
• Subscriber's Identification Number *
• Patient's Name *
• Provider Name *
• Provider Tax Identification Number (TIN) *
• Provider's Participation Status (PPO, HMO)
• Claim Date of Service *
• Type of Service
• Total Billed Charges *
• Discount Amount
• Allowed Amount *
• Excluded Charges
• Explanation of Excluded Charges (Code and Associated Key)
• Amount Applied to Deductible
• Co-Payment/Coinsurance Amount
• Total Patient Responsibility *
• Total Payment Made and To Whom *
• Benefit Level Information (Annual Deductible/Amount Applied, Annual Out of Pocket/Amount Applied, Lifetime Maximums/Amount Applied)
• ERISA Disclosure (if applicable)
• Discount Remark - "Discount For HealthLink Participation" (Must Include Network Name) *

Required information on the list above is indicated by an asterisk (*).