TREATMENT PLAN

** TREATMENT PLAN No. JOYCEJ-9C19FW18ICPAa ** DATE: 6/ 8/2016

DIAGNOSTICIAN: 12345 Aa PATIENT: Joyce, Robert M.
Greene, Harvey M. PTNT PMN: 356536481
SEATTLE DIAGNOSTIC LAB INSURED: Joyce, Robert M.
1635 E. Galer St. INSD PMN: 356536481
Seattle, WA 98118 INSURER: Prudential Insurance Co.
206-684-3245 DIAG/PR: 550.90 (Inguinal Hernia)/95

CODE/Q DESCRIPTION DATE
COMPLETED
FRQ EXPIRES CHARGE BENEFIT
C90060Q OV (Intermediate) 6/ 8/2016 1 6/8/2016 $ 50.00 $ 40.00
C93000Q EKG 6/ 8/2016 1 6/8/2016 $ NC $ --
C71010Q Chest X-Ray 6/ 8/2016 1 6/8/2016 $ NC $ --
C93734Q Pacemaker Analysis 6/ 8/2016 1 6/8/2016 $ NC $ --
C90060Q Office Visit (Intermediate)   1 6/15/2016 $ $ 40.00
C90060Q Office Visit (Intermediate)   1 6/22/2016 $ $ 40.00
C93503Q Swan-Ganz Line   1 6/15/2016 $ $ 1450.00
C33206Q Pacemaker, Repl 1 Chmbr   1 6/15/2016 $ $ 1015.00

CODE/Q TRADE/GENERIC NAME FRQ DOSE QNTY RFLS DATE FILLED CHARGE BENEFIT
P 0059Q Blocadren 2D 10mg/RTAB 60 3   $ $ 65.25

NOTE: FRQ=Frequency: 1 = one time only; 2D = twice a day.


The following instructions are for providers who are not paid subscribers to the RE·MEDI System.

TO PROVIDER: Please call 1-800-123-4567 to verify patient's continuing eligibility. After verifying the patient's eligibility, simply fill in the date and charge for each procedure performed. Then have the patient sign the bottom of this form in blue ink and mail it to the following address for reimbursement.

  RESEARCH ENTERPRISES, INC.
  1185 Faulkingham Road
  Merritt Island, FL  32952

TO PATIENT: Help Prevent Fraud.
Please mark an "X" in every blank cell under "DATE COMPLETED" in the above table and then sign on the line below.

I affirm that, to the best of my knowledge, I have received all of the treatments on this form that show a DATE COMPLETED.

________________________________________________________________________DATE:_________________
(signature)