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**Billing Sheets are in books. They are handed out by HR at the PEL office**

  1. At the top of the Billing Sheet, you will see a place to put your name and the current date that you are rendering the service.
  2. On the top right hand comer there is a place called “Stop Num”. This is meant to put your billing sheets in a chronological sequence. Please label your stops #1, #2, #3, etc as you go through your day providing services to a potential variety of facilities. If you go on a Stat or “On-Call” visit, be sure to write OC 1, OC 2, etc for distinguishing those types of stops (visits) you may make
  3. In the box labeled “Facility /Purchase Order Number/Ordering Person/Address” please print the name of the Facility where you are rendering services. If there is a PO#, please list that in the bottom corner of that box by printing {PO# l(for ex)}. If you know the person at the Facility who placed the order, please print their name underneath the name of the Facility.
  4. While you are providing services to the Facility, you may want to begin filling out your Billing Sheet services. Under “Evaluations/Service” please print the patient’s name and the type of service you are providing. Put your start/end time for providing that specific service and your total time. If it pertained to a specific patient, put the room # you were in to provide the service. Under “Code”, please print the Procedure Code you are using to describe the service given. Jfvou need to, please refer to the attached Procedure Code Description Table to assist you.Coding the Procedure is important to assist us in providing statistical analysis of our services and for the Facility to better understand the service provided. If the service was for Equipment Maintenance, please print Equipment Maintenance (EM) under the “Evaluations/Service” and then Code the type of EM Visit accordingly.
  5. Under “Item/Serial Number” please print out any equipment and/or supplies you may be delivering to the Facility and list the Room #/Patient who is receiving the delivery. Make sure you list the Quantity of the item being listed. ALWAYS include the Serial Number from the equipment as this is the only way we can track where our equipment is located.
  6. Under “Notes” you may list any extra comments you may need to make in order to complete the description of the services you have provided. An example here might be that is a Facility designate asked you to wait for a patient to arrive for a new set up, you might document the individual that gave you the approval to wait for the patient in this area of the Billing Sheet.
  7. At the bottom of the form, please fill in your Travel Time (TT) completely. TT is paid for trips from facility to facility. TT is not paid to drive to your first stop or to drive home, with the exception of portal to portal or Stat/On-Call time calls. However, you will be compensated for ALL of your mileage. (You will receive compensation for your tolls by using your PEL Transponder during work hours) When documenting your TT, you may notice that you are sometimes repeating travel times (the travel out time on stop#l will be the travel in time on stop 2). Just rewrite them on the new billing sheet.


Time Start Time End Odometer Start Odometer End Miles Total Tolls Code
Travel In 900 1300 923 981 58 0 95
Travel Out 1300 1400 981 1039 58 0 95
  • When you leave a facility always report to the person in charge and give them an update any any recommendations regarding any of the patients and/or services that were provided to them during your visit. Your signature is also required at the bottom of the Billing Sheet. The Facility person in charge and/or their designate will then need to sign the form and print their name underneath. After you fax over the Billing Sheet to the PEL office at 708- 581-7994 you may give the Billing Sheet to the Facility person in charge and/or their designate. You will retain the yellow copy of the Billing Sheet in your book for your records.