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Wednesday, March 10, 2010

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Electronic billing for DGL Users

Please complete the following details & click the submit button when finished. *Mandatory field

Main Specialist or Practice Details
Specialist/Practice Name: * Phone Number: *
Speciality: * Fax Number: *
Professional No (GMC/HPC): * Email: *
AND/OR Insurer Provider No: * Confirm Email: *
Billing Address: *
Do you use Windows 98/NT/2000/XP/Vista? *
Do you use Internet Explorer 5.5 or above? *
Billing System:
Postcode: * How did you hear about Healthcode?
Treatment Sites* Please enter the site(s) where you undertake treatment.
Site Name Town
1.
2.
3.

***If the main specialist will also be the user of the system, the below details will not be applicable.***

User Details
Please complete user details if different from the main specialist
Name: Address:
Email:
Confirm Email:
Phone Number:
Fax Number: Postcode:
Payee providers
In addition to the above specialist, please specify all other specialists that will be sending bills through the system, who are paid by the insurer directly.
If you need to add more specialists, please contact customer services directly on 01784 263 150.
Specialist Name GMC / Professional No. Speciality Treatment Site Treatment Site Town
Controlling Specialist
Where a specialist has provided treatment to patients as controlling specialist during their stay at a hospital.
If the specialist(s) billing through the system is/are not the main specialist in charge of the patients treatment, ie Anaesthetist, Oncologist, Radiology, Pathologist etc, please give details of the controlling specialists below.
If you need to add more specialists, please contact customer services directly on 01784 263 150.
Specialist Name GMC / Professional No. Speciality Treatment Site Treatment Site Town