Medical Enrollment Forms
- Enrollment in QUIC Statements Please: print, complete, sign and return (via fax or email) the attached PO. Once received, a QUIC Representative will contact you to begin service implementation.
- Enrollment in QUIC Statement Inserts Please: print, complete, sign and return (via fax or email) the attached PO. Once received, a QUIC Representative will contact you to begin service implementation.
Samples
- Standard Balance Forward Format #16 (includes separate charges, credits, & adj. columns, doc& pat column)
- Standard Medical/Open Item Format #4 (all unpaid visit detail remains listed until paid)
- Standard Balance Forward Format #2* (includes a single combined debit/credit column and doctor column). Note:*Balance Forward formats 1&2: Open Item system not needed. Balance Forward: Current cycle visit detail displayed, previous months� detail combined into one line balance).
- Standard Balance Forward Format #1* (includes separate debit and credit columns, patient column, no doctor column. Note: *Balance Forward formats 1&2: Open Item system not needed. Balance Forward: Current cycle visit detail displayed, previous months� detail combined into one line balance).
- Standard Backer Includes change of patient insurance and patient information boxes. Custom backers, at no additional cost, are offered at time of implementation printed in b/w (graphics included).
- Color Options Standard statement options offer a variety of colors to choose from.
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