ASL - Getting Started

	2001 N. Granville Ave. Muncie, IN 47303 765-284-0493

Member of
Better Business Bureau
Central Indiana
Reliability Program.

Getting Started is Easy!

When you have chosen Anesthesia Services, Ltd. as your billing service, the
following information is all we will need to begin. We will send you pre-stamped
priority mail envelopes to send your work in every week.

For every patient that you see, we will need:

A demo sheet (face sheet) name, ss#, ins., dob, etc.
Copy of patient's insurance cards
Superbill, charge sheet, (includes narrative of procedure and dx
and appropriate e&m code). We can provide a charge sheet if you
need one.
Anesthesia Record copy.

The quickest way to start using Anesthesia Services, Ltd. for all your billing
services is to complete our Start-Up Information Sheet.

Start-Up Information Sheet

Please fill out all information which applies. Press "Submit" at bottom when done. * Indicates required field
Provider Full Name*
DBA
Address
Telephone	- -
Pager	- -
E-Mail *
Please send me a brouchure and start up information in the mail.

City of birth
State County
Social Security Number (to be used as Federal Tax I.D.#)
- -
Primary Specialty:

Secondary Specialty:

Board Eligible or Certified Date
License Number
State Exp. Date
Original License Issue Date
Primary Service Location

Please list all hospitals which you will have admitting privileges.

Are you now or have you ever been licensed in any other state?
Yes No
If so, please name the state, license number and dates practiced.

Please list any provider numbers you may have for.
Blue Cross
Medicaid
Medicare

Please name the university you attended

Year Graduated

Please list your previous billing company's name, address and phone number.

If someone referred you to our billing service please name

Thank you for using our Easy Start Up Information Sheet!
We will be contacting you shortly to confirm.