PATIENT BILLING RECORD

DOWNSTATE MEDICAL ASSOCIATES

2343 Medical Building Suite 808

Downstate, New State 989021

(788) 123-4566

PATIENT BILLING RECORD

Patient Name: Davis Hilary Patient ID No.: 998080

Patient Address: 33 Wireman Road, Apt 3A, Lower Council, New State 3900

Patient DOB: 2/26/96

Parents: Katy and Herbert Hilary

Parent Contact information: 222-333-4444

Insurance: Information on File

Date of Treatment Description Coding Cost
4/4/11 Exam Established Patient Level II 99212 $195
4/4/11 Sutured 2.5 centimeter scalp wound 77777 $250
Diagnosis:
Anxiety 300.08 related to beating by classmate
Cranial abrasions and contusions