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HIPAA Compliance For Secure Billing

Protecting Patient Data With Trusted, Compliant, & Confidential Billing Solutions.

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HIPAA-COMPLIANT SERVICE REQUEST FORM

IMPORTANT – PLEASE READ CAREFULLY

Confidential Information – Please complete and return securely.

1. PROVIDER / PRACTICE INFORMATION

2. PRACTICE PROFILE

3. SERVICES REQUESTED (CHECK ALL THAT APPLY)

4. HIPAA AUTHORIZATION & DATA USE

By submitting this request form, you acknowledge and authorize the following:

  1. Purpose of Use: The information you provide will be used solely for the purpose of scheduling a consultation, discussing your practice's needs, or preparing a preliminary billing system audit.
  2. Confidentiality & Security: All information submitted through this form will be kept confidential and handled in compliance with the Health Insurance Portability and Accountability Act (HIPAA).

5. AUTHORIZATION

Evocare Billings Service Request Form

HIPAA-COMPLIANT SERVICE REQUEST FORM

IMPORTANT - PLEASE READ CAREFULLY

Confidential Information – Please complete and return securely.

1. PROVIDER / PRACTICE INFORMATION

2. PRACTICE PROFILE

3. SERVICES REQUESTED (CHECK ALL THAT APPLY)

4. HIPAA AUTHORIZATION & DATA USE

By submitting this request form, you acknowledge and authorize the following:

  1. Purpose of Use: The information you provide will be used solely for the purpose of scheduling a consultation, discussing your practice's needs, or preparing a preliminary billing system audit.
  2. Confidentiality & Security: All information submitted through this form will be kept confidential and handled in compliance with the Health Insurance Portability and Accountability Act (HIPAA).

5. AUTHORIZATION

OR

Submission Instructions:

Please complete this form and submit. For any questions, please contact us at info@evocarebillings.com.

  • 1209 Mountain Road PL NE Ste R Albuquerque, NM 87110
  • info@evocarebillings.com
  • +1 (323) 412-5399
  • +1 (341) 222-3200
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