White Crane Billing Solutions
For Current White Crane Therapists

Forms

Most Often Used Forms

Services Performed Reporting Form

This is the form you use to submit claim information, including patient name(s) and date(s) of service. It is also where you tell us if anything is different from your usual for any given date(s).

Sample Services Performed Reporting Form

This is filled out with a variety of examples of how you might convey claim information to White Crane.

Subscriber and Client Information Forms

Page 1 includes basic client/subscriber information and primary insurance information. Note in particular that the procedure listed on this form is the one you expect to use most often with this client. Exceptions will be noted per date of service on the Services Performed Reporting Form

Page 2 includes information about supplemental insurance(s) and/or supplemental information that might be needed. This can be printed or copied to the backside of Page 1 to save paper. This form is only needed in some circumstances (secondary insurance, special Medicare information, or unusual additional insurance information. When none of these apply, this form is not needed. When this form is appropriate, it may be printed on the back side of the Subscriber and Client Information Form (Page 1).

ClientAB both pages above in one file. 

Secured Forms for Email Submissions

If you wish to submit Subscriber and Client Information or Services Performed Reporting Forms via email, remember that the information contained in these forms is Protected Health Information (PHI) per HIPAA, and may not be sent over email unless encrypted. For this purpose, we have created two forms:

ClientABSecure and SvcRptV2Secure.

Similarly, if you wish to submit Charge Services Form, Provider Information Form, or Group Individual Providers Form, each of which contains your own private information, we have created their secure counterparts:

ChargeSvcsSecure and ProviderSecure and 

GroupMembersListSecure

Download these files to your computer. If you get a warning that the files cannot be scanned for viruses, it is because they are encrypted. Download them anyway. 

To open them, you will use the same encryption key used for all response files from White Crane. Open the file with the key, using any PDF reader. Then enter the information into the file on your computer and save the file under a different name using the SAVE AS.function (this will rename the file so you don't lose the original, blank form). When saved, the new file should have all the information in it and still be encrypted, which will allow you to securely attach it in an email to White Crane.

Submitted once and only updated when necessary

Charge Services Form

Use this form if you would like to authorize payment by VISA or MasterCard for ongoing services provided by White Crane.

Provider's Fee Schedule

This form tells White Crane your fees for the Procedure Codes you use.

Provider Information Form 

This is a 2-page form that provides White Crane with information necessary to set up your account with White Crane.

Group Individual Providers Form

This is a 1-page form listing the provider information for individual members of a group practice.

Mailing Labels

White Crane Mailing Labels 5260

White Crane Mailing Labels 5351

These are sheets of mailing labels that can be printed to Avery 5260 or 5351 labels

Submit a problem

Please email White Crane. Remember, this is not a secure communication site. Please mask all client identifying information, for instance by using first name and last initial only.

Include your name and/or company name, your phone number, your fax number, and as complete a description of your problem, question, or concern as possible. The more detailed your description, the faster your problem can be solved.

About Response File Information

 >>Read about Response File Information here

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