Billing for Non$-$Emergency Hospital Visits

Assignment #$4-$ Module D$2$

Date:

Student Name:

Physician Name Physician Number

Last Name First Name Date of Birth $($YYYYMMDD$)$ Health # Version

Admission Date

$($YYYY$-$MM$-$DD$)$ Facility Name and Master Number Referring Physician Name & Number

SERVICE INFORMATION

Date $($YYYY$-$MM$-$DD$)$ Code # Services Fee Diagnosis

Physician Name Physician Number

Last Name First Name Date of Birth $($YYYYMMDD$)$ Health # Version

Admission Date

$($YYYY$-$MM$-$DD$)$ Facility Name and Master Number Referring Physician Name & Number

SERVICE INFORMATION

Date $($YYYY$-$MM$-$DD$)$ Code # Services Fee Diagnosis

Physician Name Physician Number

Last Name First Name Date of Birth $($YYYYMMDD$)$ Health # Version

Admission Date

$($YYYY$-$MM$-$DD$)$ Facility Name and Master Number Referring Physician Name & Number

SERVICE INFORMATION

Date $($YYYY$-$MM$-$DD$)$ Code # Services Fee Diagnosis

Physician Name Physician Number

Last Name First Name Date of Birth $($YYYYMMDD$)$ Health # Version

Admission Date

$($YYYY$-$MM$-$DD$)$ Facility Name and Master Number Referring Physician Name & Number

SERVICE INFORMATION

Date $($YYYY$-$MM$-$DD$)$ Code # Services Fee Diagnosis