JEFFERSON HEALTH SYSTEM
PHYSICIAN BUSINESS SERVICES
IDX CUSTOM REPORT REQUEST FORM
Attn: Merle Charlton / Maureen McDade/ Doreen Kornrumpf
Fax# 215-503-0092 / Fax# 215-955-0387 / Fax# 215-923-3613
REQUESTOR:______ ______________________________________
DATE:________________________
PHONE #:___________________________________ SEND TO:______________________________
What is the purpose /reason for request?______________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Please enter your report selection criteria:
Group #: ____________ Division #:___________ Billing Area #:______________________
Location: ___________________Providers #: ______________________________________
CPT(s): ___________________________________ DX ONE: ______________________________________
FSC: ____________________________________ Invoice Creation Period: ___________________________
Paycode: _____________________________ Posting Date: ___________________________________
Other Criteria: _________________________________________________________________________
In the space provided below, illustrate what you would like your report to look like. Please include titles, column headings, one or two lines of detail, subtotals, grand totals and the sort order of the information included in the report and any page breaks.
Request authorized by: _______________________________________ Date: ________________________
Completed by: _______________________ Date: __________________ Delivered on: ________________