Housecall/Site Visit Submission Form

****Please use this form**** This needs to be filled out for EACH SITE VISIT AND HOUSECALL PERFORMED. This is how our accounting department will make sure provider's get paid for doing housecalls and site visits, and which partner's area they are being performed in.

This needs to be filled out for EACH SITE VISIT AND HOUSECALL PERFORMED on a NON-MEMBER.

Use this for Cargo Glide and Black Bear. ***$428 for this service ($150 Enrollment Fee + $149 One Month's Membership + $129 House Call Fee ***