Billing Form - Center for Fetal Medicine

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Center for Fetal Medicine and Women's Ultrasound

6310 San Vicente Blvd. | Suite 520 | Los Angeles, CA 90047 Tel: 323-857-1982 | Fax: 323-857-5336

Billing Form (Genetic Counseling)

First Name

Last Name

Male

Female

Patient Name

DOB

Address

City

State

Zip

Spouse / Partner Name

Emergency Contact

Tel

Date of Appointment

Billing Information Section 1

Physician

Medicare

Inpatient

OutPatient

Card

State

California PNS Program

Patient/Self-PAY

Payment

Section 2 Copy of insurance card (fornt and back) required, attach copy of authorization if available.

Insurance/PPO

Blue Cross

Medical Group/IPA

HMO Attach

Insurance company details

Company Name

Billing Address

City

State

Zip

Tel

Name of Insured

Policy

Group

Name of Employer

Relation of Insured

Date

Center for Fetal Medicine

Our Location

6310 San Vicente Blvd,
Suite 520
Los Angeles, CA 90048

Call Us: 323-857-1952
Fax Us: 323-857-5336
Records sent to [email protected]
Monday-Friday: 8:00am – 4:00pm

2001 Santa Monica Blvd,
Suite 870W
Santa Monica, CA 90404

Call Us: 323-857-1952
Fax Us: 323-857-5336
Records sent to [email protected]
Monday-Friday: 8:00am – 4:00pm