Cash Research Request

Date

Facility Dental FT HB HHC PB

Supervisor Name

Department/MRSI

FSR Full Name

EXT.

Email

Insured Name

Invoice/Patient #

Name of Ins. Co.

Patient Name

DOS

Date Claim Paid

Check Date

Type of Payment
Check Credit Card NO PAY Remit

Missing Payment Amount

Check/Payment #

Check/Payment Clear Date

Check/Remit Date

CC Number

CC Type

CC Reference #

Bulk Ck. Amount $

Parent Payments Paid At
Hospital Mailed Online

If Hospital What Department

Has Copy of Cleared Check Been Requested

Other Patient Name Paid on Same Voucher and Date of Service

Spoke To

Insurance Company Phone Number

Payment Sent to (Please note address verified)

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