Service Providers Tab - Professional

Select the rendering provider from the drop-down menu.

Rendering provider last name. The rendering provider is the person or company (laboratory or other facility) who provided the care.

Rendering provider first name.

Rendering provider middle name or initial.

Suffix to individual name.

Rendering provider identification.

Code designating the provider type, classification, and specialization of the rendering provider for this claim. The taxonomy can be different for the same provider on different claims.

Select the referring provider from the drop-down menu.

Referring provider last name. The referring provider is the person or company who referred the patient to the rendering provider for treatment.

Referring provider first name.

Referring provider first name.

Suffix to individual name.

Referring provider identifier.

Add information on an additional referring provider.

Select the supervising provider from the drop-down menu.

Supervising provider last name. Required when the rendering provider is supervised by a physician.

Supervising provider first name.

Supervising provider middle name or initial.

Supervising provider name suffix.

Supervising provider identifier.

Select the service facility from the drop-down menu.

Individual last name or organizational name where the patient received treatment.

Laboratory or facility primary identifier.

Address information of the service facility.

Laboratory or facility postal zone or zip code. When a user enters a zip code in a zip code field and clicks tab to move to the next field, the city and state fields are automatically generated based on data received from the USPS. Note: This replaces any data already entered in the city/state fields.

Laboratory or facility city name.

Laboratory or facility state or province code.

Code identifying the country of the laboratory or facility.

Code identifying the country subdivision.