REFERRAL BILLING QUESTIONNAIRE
Complete Name of Study:
Short Name of Study (15 characters max.):
Ultimate Payor (Drug Co., Grant, Etc.):
Contact Person: Telephone Number:
BILLING INFORMATION
Person Who Will Receive Bill:
Complete Billing Address:
OTHER INFORMATION
Date Study to Begin:
Date Study to End:
Please (briefly) describe exact services to be provided by the hospital:
*Note: Referral billing is used to bill outside entities for patient services. We do not bill patients and/or insurance companies directly. Please do not use a referral guarantor number if the patient and/or insurance company is to be billed.
Please Return Questionnaire To: University Hospital
Accounting
Attn: Rod Michael
1650 University Blvd. NE
Albuquerque, NM 87106
(505)272-0252; FAX:272-3279
Payment Terms are Net 30 Days
Accounting Use Only
Referral Account Number: Short Name:
Disc. (If any): Disc. Approved By: