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: 12/12/2011

 UB04 Billing Instructions
    Date Posted: 12/12/2011

 PBH 837I (Institutional) Companion Guide 5010
    Date Posted: 11/16/2011

 PBH 837P (Professional) Companion Guide 5010
    Date Posted: 11/16/2011

 CMS1500 Billing Instructions
    Date Posted: 11/9/2011

 PBH Health Insurance Form
    Date Posted: 11/9/2011

 Place of Service Crosswalk
    Date Posted: 10/20/2011

 Electronic Funds Transfer Form
    Date Posted: 10/7/2011

 PBH 2011 Sliding Fee Schedule
    Date Posted: 10/5/2011

 PBH Financial Status Report (FSR)
    Date Posted: 10/3/2011

 PBH Claims Request Form
    Date Posted: 9/29/2011

 Active Service List by Service Category
    Date Posted: 7/21/2011

 PBH Reason Codes
    Date Posted: 6/9/2011

 PBH 2010 Sliding Fee Schedule
    Date Posted: 2/21/2011

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

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