Elderly Waiver Billing Form

Insurance Billing Requirements

Date*

Contact Information

Client Name*

Address*

City*

State*

Zip*

Phone*

Email*

Contact Person (if different)

Address

City

State

Zip

Phone

Insurance Information

Insurance Company*

Insured ID*

Group Number*

Project Information

Project Description*

Date of Service Start*

Date of Service End*

Diagnosis Code (Only One Code)*

Date of Birth (D.O.B)*

Gender*MaleFemale

Authorization No.*

Amount*

Client Spend Down*YesNo

Our Recognized Expertise

Certified and insured contractors with over 30 years of construction experience. We are proud to be recognized for our hard work and commitment to assist the aging communities in Minnesota.

CAPS LIC: September 2012
MN Elevator Lic: LC 716918
MN Builders Lic: BC 590012

CAPS LIC: September 2012
MN Elevator Lic: LC 716918
MN Builders Lic: BC 590012
NPI/UMPI #1669715397

Ocel Builders
19215 Flagstaff Avenue
Farmington, MN 55024

DHS Waiver Referral Form
Service and Warranty Form
Elderly Waiver Billing Form