Fee Schedule Request Form

HEALTHLINK | FEE SCHEDULE REQUEST FORM

Fee Schedule Request Form

If you are a HealthLink participating physician, hospital or other health care professional, please complete this form to request allowable amounts. Be sure to fill in all sections of the requested information to ensure accuracy.

Requestor Information

* Name

* Phone

* Email

Provider Information

* Provider Name

Provider HealthLink Number

* Provider TIN

Provider NPI

Provider Email Address (if different from the requestor's)

CPT Codes

Enter CPT Codes

Please enter one CPT code per line:

OR

Request a full fee schedule