Common Contracts
1 similar Payment Agreement contracts
HUMAN RABIES BIOLOGICALS PAYMENT AGREEMENT AND SURVEILLANCE REPORT (Version 12/10/10)Payment Agreement • January 3rd, 2011
To fully complete this form, the person distributing the biologicals should interview the patient or guardian. Additionally, a signature and other documentation must be obtained from the patient or guardian before the biologicals are distributed. The ordering physician’s UPIN/ NPI numbers are required when billing private insurance.
