NAME OF PATIENT
PATIENT I.D. #
CHART #
RESPONSIBLE PARTY NAME
BIRTH DATE
ADDRESS
TELEPHONE NEXT APPOINTMENT _________ DAYS ________WKS ______MOS
CITY
STATE
ZIP
ASSIGNMENT AND RELEASE: I authorize and request that payments under my insurance programs be made directly to the above provider for any services furnished to me. I also authorize the provider to release any information needed for payment of claims. I further permit copies of this authorization to be used in place of the original. Signed___________________________________________________________________Date________________________
PATIENT or RESPONSIBLE PARTY
PHYSICIAN'S SIGNATURE
PROCEDURES CPT-4 OFFICE u Minimal u Brief u Limited u Intermediate u Extended u Comprehensive u Sunday Visit NEW EST 90030 90000 90040 90010 90050 90015 90060 90017 90070 90020 90080 99054 99054 FEE u Massage u Nicotine Withdrawal u Nutrition Consultation 90610/90641 95000 95001 95020 95021 95022 LABORATORY IMMUNIZATION/INJ/SKIN TEST HEALTH EXAM u (>18) u (12-17) u (5-11) u (1-4) u (0-1) NEW EST u DPT u OPV u MMR u Flu u ISG 90701 90712 90707 90724 90741 u DT u TD u TT u CoccI u PPD u Tine 90702 90718 90703 86490 86580 86585 90788 90782 20600/20605/20610 20550 90750 90760 90751 90761 90752 90762 90753 90763 90755 90764 u CBC u VDRL u Glucose, Blood u SMAC u T3T4T7 u HDL u HB u Sed Rate u Monospot u Strep Screen u TSH u UA u Urine Culture OFFICE SURGERY u I & D Abscess u Excision, Benign u Excision, Malignant u Laceration Repair 10060/10061 u Urine Preg. Test u Stool for Occult Blood u Pap Smear u Vaginal Wet Prep u Vaginal Yeast Culture DIAGNOSIS ICD-9-CM ACCIDENT u Abrasion, Skin u Burn u Foreign Body, Skin u Fracture u Head Injury u Laceration u Soft Tissue Inj. CARDIOVASCULAR u Angina u Arrhythmia u ASHD u Cerebrovascular Dis u Chest Pain u Congestive Heart Fail u Electrolyte Imbalance u Heart Murmur u Hypertension u Mitral Valve Prolapse u Myocardial Infarction u Peripheral Vas Dis u Varicose Veins DERMATOLOGY u Acne u Cellulitus Abscess u Dermatitus u Herpes u Herpes Zoster 706.1 682.9 692.9 054.1 053.9 413.9 427.9 414.0 437.9 786.50 428.0 276.9 785.2 401.9 424.0 410.9 440.2 454.9 u Cataract u Cerumen Impacted u Conjunctivitis u Epistaxis u Eustachian Tube Dys. u Foreign Body, Cornea u Laryngitis u Otitis Externa u Otitis Media u Pharyngitis u Sinusitis u Tonsillitus u Vertigo 919.0 949.0 919.6 829.0 854.0 879.8 859.9 u Gout u Hyperlipidemia u Hyperthyroidism u Hypothyroidism u Malnutrition u Obesity HEENT u Allergic Rhinitis 477.9 366.9 380.4 372.30 784.7 381.81 930.0 464.0 380.12 382.9 462 473.9 463 780.4 u Anemia u Fever u Insomnia u Lymphadenopathy u Syncope GENITOURINARY u Albuminuria u Epididymitis u Hematuria 791.0 504.9 599.7 u Hives u Impetigo u Ingrown Toenail u Skin Infection, Fungal u Warts ENDOCRINE u Diabetes Mellitus 250.9 274.9 276.8 242.9 244.9 263.9 278.0 708.9 684.0 703.0 111.9 078.1 GASTROINTESTINAL u Abdominal Pain u Cholecystitis u Cholelithiasis u Constipation u Diarrhea u Diverticulitis u Diverticulosis u Dysphagia u Esophagitis u Gastritis u Gastroenteritis u Hemorrhoids u Hepatitis u Hernia u Irritable Bowel Synd. u Peptic Ulcer u Rectal Bleeding GENERAL 285.9 780.6 785.6 780.2 789.0 575.1 574.2 564.0 558.9 u Incontinence u Prostatic Hypertrophy u Prostatitis u Urethritis u Urinary Tract Infection GYNECOLOGY 795.0 626.6 626.0 V72.3 611.72 616.0 625.3 617.9 610.9 627.2 614.9 625.4 616.10 INFECTIONS u Flu Syndrome u Valley Fever MENTAL DISORDER u Anxiety 300.0 OTHER DIAGNOSIS 487.1 075 114.9 u Asthma u Bronchitis u COPD u Croup u Pleurisy u Pneumonia u Upper Respiratory Infection 788.3 600.0 601.9 597.80 599.0 u Behavioral Disorder u Depression u Stress MUSCULOSKELETAL u Arthritis u Back Pain u Back Strain u Bursitis u Cervical Strain u Tendonitis NERVOUS SYSTEM u Headache u Migraine u Neuropathy u Siezure Disorder RESPIRATORY u Abnormal Pulm Function Test 794.2 493.9 490 496 464.4 511 486 465.9 784.0 346.9 355.9 780.3 716.9 724.5 847.9 727.3 847.0 726.71 V71.02 311 306.9 85031 86592 82947 80019 80070 83718 85018 85650 86300 86235 84443 81000 87086 84703 82270 88150 87210 87102 u CC u Cash u Ck # Balance $___________________ Payment $___________________ Previous Balance Today's Charges $___________________ $___________________ u Allergy Tests Scratch 1-30 u Allergy Tests Scratch 31-60 u Allergy Tests ID u Allergy Tests ID u Allergy Tests ID 1-10 11-20 21-30 97124 u Electrosurgical Destruction u Electrocautery Cervix u Appl of Cast u Punch Biopsy u Supplies, Materials u Aspir. of Breast Cyst 11100 99070 19000 57510 u GC Culture u Chlamydia u Endometrial Biopsy u EKG With Interp u Spirometry u Routine Venipuncture u Specimen Handling 87081 86235 58102 93000 94375/94010 36415 99000
OTHER PROCEDURES
u Pneumo 90732
u Allergy 95115/95117 u HIB 90737 u IM Antibiotic PROCEDURES u Cerumen Removal u Anoscopy u Colonoscopy, Fiberoptic u Colonoscopy with Biopsy u SVN Therapy u Physiotheraphy u Ultrasound u EGS 69210 46600 45330 45331 97110 97128 97118 94664/94665 u IM Therapeutic u Arthrocentesis u Trigger Pt, Ganglion
562.11 u Abnormal Pap 562.10 u Abnormal Uterine Bleeding 787.2 530.1 535.0 558.9 455.6 573.3 553.9 564.1 533.9 569.3 u Amenorrhea u Annual Female Exam u Breast Lump u Cervicitis u Dysmenorrhea u Endometriosis u Mammary Dysplasia u Menopausal Synd. u Pelvic Inflammatory Disease u PMS u Vaginitis
780.52 u Mononucleosis