Charge Description Master Survey

Instructions: Please complete the following survey regarding your organization. If your organization has multiple facilities, seperate forms must be submitted for each facilities.

January 1, 2019 Charge Description Master Upload:

January 1, 2019 Charge Description Master Upload by HCPCS or CPT Code:

Provider Information:

Parent Organization Name:

Business Name: *

Street Address: *

Address Line 2

City: *

State: *

Zip Code: *

Phone Number: *

Extension:

Email Address: *

Federal Tax ID Number: *

Medicare Identification Number:

Organization NPI: *

Provider Speciality Type: *

Accrediting Organization(s):

Check this box if your business was not in existence on or before January 1, 2019.

Any additional information ReviewWorks needs to know about your charge description master or rate sheet:

Your submitted charge description master or rate sheet will be validated for pricing accuracy against claims received from your organizations.

Signature of individual completing document: *

clear

Title of individual completing document: *

Email address of individual completing document: *

Submission Date: * +

Charge Description Master Survey

Provider Information:

*Your submitted charge description master or rate sheet will be validated for pricing accuracy against claims received from your organizations.*

Your submitted charge description master or rate sheet will be validated for pricing accuracy against claims received from your organizations.