Print Fillable Form
Feature Overview
⚠ OPTIONAL FEATURE
Print Fillable Form is not enabled by default. It must be manually added to the account by a developer or admin before it can be used.
What Is Print Fillable Form?
Print Fillable Form generates a filled-out form directly from a billing claim or claim transaction. It pulls all the relevant billing, patient, insurance, and payment details from the record and lays them out in a ready-to-print format — no manual data entry required.
Note: Forms will require review as these were not audited by a biller. Any additional forms missing from the existing list are welcome.
What Gets Filled In Automatically?
The form is populated with information pulled directly from the claim record, including:
- Patient information — Full name and insurance member/group ID.
- Facility details — Address, state, tax ID, and billing address.
- Claim charges — Up to 7 charges per page, with totals calculated automatically. Multiple pages are generated if there are more than 7 charges.
- Insurance payment details — Amounts allowed, paid, deductible, and co-insurance by payer.
- Medicare & Medicaid specific fields — PTAN, ICN, member ID, group number, payment date, and applicable reason codes — filled in only when the relevant payer type is present on the claim.
- Clearing house info — Submitter ID and clearing house name, when the form is generated from a submitted claim transaction.
Multi-Page Claims
If a claim has more than 7 line items, the form will automatically span multiple pages — one page for every 7 charges. Each page is a complete, self-contained form with its own totals.
Getting Access
This feature must be manually added to your account by a developer or admin. Contact your admin or support team to request access.