Lactation Visit Receipt Order Form-Single PP
This order form is for a Private Practice IBCLC who works as a sole practitioner.
This form is only for the HEADER information to go on the Lactation Visit Receipt (lactation superbill).This order will NOT be filled if PAYMENT is not made by PayPal. PayPal also takes all major credit and debit cards. Ordering is a TWO STEP process. After completing this form, continue to PAYMENT page to complete your order.
DOUBLE check your entry on this form, if you want changes after you have submitted your information due to you making typos in filling out the form or change of mind as to information, it will incur a fee for changes. If you are unsure of your business name or address or phone you wish to use, wait to order till you are sure.
Contact Phone Number Regarding This Order
Note email replies and order will come from email of firstname.lastname@example.org
Set your email to accept this email to prevent it going to SPAM.
Your contact email which your order will be sent to:
Sample Header for Lactation Visit Receipt below -
Only 5 lines, header will be centered on top of superbill - No logos (space does not permit)
Pat Lindsey, IBCLC
Registered Board Certified Lactation Consultant-IBLCE # L-26768
P.O. Box 9999, Anytown, FL 09999 - Phone 1-888-900-0000
NPI # 1234909876 EIN # 59-999999 CAQH # optional
First Line - Your Business Name
Second Line (sug. YOUR name, IBCLC, other initals)
Third Line (sug. International Board Certified Lactation Consultant and your new IBLCE number beginning with L- )
Fourth Line (sug. Business Address, City, Zip & Business PHONE number - insurance does not want email or website)
Be SURE to include the Business Phone Number with your Business mailing address!!!
Fifth Line (NPI & EIN - these are a must-all payers will require them. If you have a CAQH number it can also go here)
REMEMBER to Double check your entry above for accurate typing and information. Changes to forms due to your mistakes, typos or change in information will result in charges for changes.
Who referred you to the LVR forms?
Your referral person's email address if you have it?