Sherry Denise Cleaver is a patient in the medical office where you work. Name: Sherry Denise Cleaver,Est. Patient,Birth Date:July 1,2009, Responsible person: James Cleaver, Relationship to Patient:father, Insureds plan:BMA PPO; Diagnosis of otitis media, left ear, on May 13,2016;the charge is $22 for a CPT 99211. The office collected a copayment $10 and waits for payment for insurance companies on claims.

Supply the following data elements: Subscriber, Patient, Relationship to Patient to Subscriber, Claiming Filing Indicator Code, Total charge, Amount collected, Place of service,Diagnosis code, Date of service, and Procedure code/Charge?