Form batch header is a field that is found in the lower left-hand corner of most standard forms. The purpose of this field is to identify the form and indicate that it is part of a series. By filling out the form batch header, you make it easier for the person who will be processing your forms to locate and track them. In addition, if you have any questions about how to complete a particular form, the batch header can help provide clarification. To create a form batch header, start by typing "Form Batch Header" in the top row of the first column on your form. Fill in all other information as appropriate, including the name of your company or organization and the date. Once you have completed all fields, make sure to print out your form so that it can be included with your other submissions.
| Question | Answer |
|---|---|
| Form Name | Form Batch Header |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | nib provider your, medibank batch header, nib batch header, medibank private batch header |
abn 83 000 124 381
nib MediGap Department Reply Paid 62208 NEWCASTLE NSW 2300 Phone 1300 853 530 (option 1) Fax 02 4925 1906
Email medigap@nib.com.au Web providers.nib.com.au
This medical practice agrees to bill nib MediGap directly for the services on this account and accepts the terms of MediGap as set out in the current Products & Procedures Guide. The patient/nib customer has been advised of the payment arrangements for the services on this account and no further payment is required.
nib MediGap is a NO GAP scheme.
BATCH HEADER OR ACCOUNT FORM
Instructions |
• Complete parts 1 and 4 if attaching your own accounts. (Your accounts much include all information in parts 2 and 3) |
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• Complete parts 1, 2, 3 and 4 if using this form as your account. |
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PART 1 - BATCH DETAILS |
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Provider’s name |
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Provider’s number |
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Total value of |
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Number of |
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Date lodged |
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$ |
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claims in batch |
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claims in batch |
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PART 2 - ACCOUNT DETAILS
Patient’s name
*Medicare no.
Patient’s date of birth
Hospital name
REFERRAL DETAILS
Referral date
Referring doctor’s name
Customer’s name
(IF NOT THE SAME AS THE PATIENT)
Your reference number
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Referral period: |
3 months |
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nib customer number
*Patient reference no. |
*PLEASE ENSURE CORRECT MEDICARE |
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AND REFERENCE NO’S ARE STATED |
Hospital provider number
Total charge
6 months |
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12 months |
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18 months |
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Indeinite |
Referring doctor’s provider number
PART 3 - SERVICE DETAILS |
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Service conditions - tick () below if applies to each service |
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Number |
Date |
Full cost |
Part of a |
Referred |
Designated |
Considered |
Performed |
Self |
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of |
of |
of |
multiple |
within a |
‘not normal’ |
‘not for |
on separate |
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determined |
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MBS Item no. |
Description of service |
patients |
Service |
service |
procedure |
hospital |
after care |
comparison’ |
sites |
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1
2
3
4
Assisting doctor’s name
Surgeon’s name
Assisting doctor’s provider number
Surgeon’s provider number
PART 4 - AUTHORISATION |
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• Are the services on this claim related to compensation? |
Yes |
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No |
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• Does your practice have inancial interests in any hospital or health insurance product? |
Yes |
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No |
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• Has the patient/nib customer been provided with informed inancial consent? |
Yes |
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No |
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Declaration
The professional services on the attached account were provided by or on behalf of a doctor in this practice and were rendered to a private
I declare that the charges above are full cost for services provided and that no additional charges have been placed on the customer for those services.
Signature of authorised person |
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Date |
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For assistance or more information, please call the MEDIGAP HOTLINE 1300 853 530 (option 1)
nib0056_0809