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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