WebPT Billing

Location Information

Location Code (required)

Location Name (required)

Address (required)

City (required)

State (required)

Zip Code (required)

Phone

Fax

Practice (required)

Exclude From Lookups

Is Active

Remove Logo

Tax Identification Number

National Provider Identifier (required)

Location Identifier (required)

Claim Code (required)

Medicare Type

Default Provider Group Number

Submitter ID

Supply Only Charge Entry

Apply Tax

Same as Location

Name

Address

City

State

Zip Code

Phone

Phone Extension

Return Address Same as Location

Return Address Description

Return Address

Return Address City

Return Address State

Return Address Zip Code

Statement Note