Finance Forms

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Finance Claim Forms for providers. Please click on the links below to access the information you need. Should you have any questions please contact the Finance Department at 704-721-7000

Finance Forms

Last Updated: 6/30/2010

 Finance FAQ's
    Date Posted: 6/30/2010

 Active Service List by Service Category
    Date Posted: 4/2/2010

 PBH Reason Codes
    Date Posted: 1/19/2010

 Electronic Funds Transfer Form
    Date Posted: 11/18/2009

 CMS1500 Instructions/Cheat Sheet
    Date Posted: 9/28/2009

 UB04 Billing Instructions/Cheat Sheet
    Date Posted: 9/17/2009

 PBH Claim Adjustment Request Form
    Date Posted: 6/17/2009

 Claim Adjustment/Inquiry Form Instructions
    Date Posted: 1/29/2009

 Place of Service Crosswalk
    Date Posted: 10/13/2008

 Provider Claim Inquiry Form
    Date Posted: 10/2/2008

 Provider Refund Detail Form
    Date Posted: 9/18/2008

 PBH Health Insurance Info Form
    Date Posted: 7/23/2008