Ww2.nasbhc.org
| | Westside Park SBHC - SBCDPH | | | |
| | | | | Billing/Encounter Form | | | |
|Date_XX-XX-2007______ Clinic ID # __10 a Site: ADL.SHE |
|Name __Suzi Q_________________________ Gender___F___ DOB __________ | | |
|Address___123 Main St, Somewhere, CA 92XXX_____________________ SS#__XXX-XX-XXXX__________________ |
|Insurance Type __M/C________ verified [XX ] yes [ ] no Income $ _________ Sliding Scale Fee $ ______ |
| | | | | | | | |
| | | | | |904|IZ Admin| |
| | | | | |72 |# 4 | |
| | | | |TC |min____ | |
| |994|Individual 15 min. | | | | | | Tonsillitis, acute 463.00 |
| |01 | | | | | | | |
|Assigned physician: [ ] Bruce Smith, MD | | | |[ ] Other__________________________ | | | |[ ] Penny Winkleman |
Coding handout 10
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