School-Based Health Alliance
| | Westside Park SBHC - Billing/Encounter Form | | | |
|Date_____________ Clinic ID # _______ Site: ADL.SHE |
|Name _____________________________ Gender______ DOB __________ | | |
|Address_______________________________________________________ SS#__________________________ |
|Insurance Type ___________ verified [ ] yes [ ] no Income $ _________ Sliding Scale Fee $ ______ |
| | | | | | | | |
| |Code|Desc| | |Code |Desc| |
| | |ript| | | |ript| |
| | |ion | | | |ion | |
| | | | | |90472 |IZ | |
| | | | | | |Admi| |
| | | | | | |n # | |
| | | | | | |4 | |
| | | | |TC |min_| |
| | | | | |___ | |
| |99401 |Individual 15 min. | | | | | | Tonsillitis, acute 463.00 |
|Coding Handout 4 | | | | | | | |[ ] Penny Winkleman |
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