Medical Bill Negotiation Referral Form

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Requesting Company:  Address: 
Contact Person:  Telephone: 
Fax:  Email: 
Date: Jurisdiction State:
Name of Patient:  Injury Date:
Name of Facility: Control or Case Number: 
Admission Date: Discharge Date:
Billed Amount: Fee Schedule Reduction Applied?
Special Instructions:
Please conclude or return by:

Please upload all related attachments (as either images or PDFs) such as billing form, EOBR, itemization operative report using the browse buttons below or email to
Browse to Select Files:  


* If fee schedule reductions have not previously been applied Woodall & Broome will calculate in accordance to state reimbursement guidelines on your behalf. All reductions achieved thru negotiation are savings below state reimbursement amount.