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Text File  |  1996-02-07  |  11KB  |  87 lines
  1. 85    0     12800  0 11  8 41  8 521 8 00  0                                                                                  
  2. 0AGADW010112293112293931122  1 11487 Influenza                 99214     CA65.00          112293            1     5 99A       
  3. 0AGADW010112293112293931122  1 1100000002 Cash                 CASH      SA-2.60                            1     5 99A0      
  4. 0AGADW010112293112293931019  1   Insurance Check #578          BP        IA-46.08         112293112293      1     0 0  1      
  5. NAGADW010112293      931122  1 Blue Cross/Blue Shield was billed.                                                             
  6. NAGADW010112293      931122  1 Mutual of Omaha was billed.                                                                    
  7. 0ANALO011112293112293931122  1 11463.0 Tonsillitis             99213     CA60.00          112293            1     5 99A       
  8. 0ANALO011112293112293931122  1 11Patient Copay-Check #522      COPAY10   OA-10.00                           1       99A0      
  9. NANALO011112293      931122  1 Cigna Health Plan was billed.                                                                  
  10. 0ANALO011112393112393931018  1   Insurance Write-Off           CIGWROFF  BA-65                              1     0 0  1      
  11. 0ANALO011112393112393931018  1   Insurance Check #             CIG       IA0                                1     0 0  1      
  12. 0BRADO010112393112393931123  4 11531.90 Gastric Ulcer          99213     CA60.00          112393            1     5 99A       
  13. 0BRADO010112393112393931123  4 11Patient Copay-Check #3020     COPAY10   OA-10.00                           1     5 99A0      
  14. NBRADO010112393      931123  4 FHP Health Care was billed.                                                                    
  15. 0BRADO010112493112493931019  1   Insurance Write-Off           FHPWROFF  BA-220                             1     0 0  1      
  16. 0BRADO010112493112493931019  4   Insurance Check #             FHP       IA0                                1     0 0  1      
  17. 0BRIJA014112293112293931122  3 11463.0 Tonsillitis             99213     CA60.00          112293            1     3 99A       
  18. 0BRIJA014112293112293931122  3 11Patient Copay-Check #410      COPAY10   OA-10.00                           1     3 99A0      
  19. NBRIJA014112293      931122  3 FHP Health Care was billed.                                                                    
  20. 0BRUTO010112393112393931123  1 11465.9 Upper Respiratory Infect99213     CA60.00          112393            1     5 99A       
  21. 0BRUTO010112393112393931123  1 11Patient Copay-Check#3012      COPAY5    OA-5                               1     5 99A0      
  22. NBRUTO010112393      931123  1 Humana Health Care was billed.                                                                 
  23. 0BRUTO010112493112493931020  1   Insurance Write-Off           HUMWROFF  BA-27                              1     0 0  1      
  24. 0BRUTO010112493112493931020  1   Insurance Check #             HUM       IA0                                1     0 0  1      
  25. 0CHOCL010112493112493931124  2 11269.2 Vitamin Deficiency      99211     CA25.00          112493            1     5 99A       
  26. 0CHOCL010112493112493931124  2 11269.2 Vitamin Deficiency      81000     CA11.00          112493            1     5 99A       
  27. 0CHOCL010112493112493931124  2 1100000102 Cash                 CASH      SA-7.20                            1     5 99A0      
  28. 0CHOCL010112493112493931019  2   Insurance Check #5799         CH        IA-40.8                            1     0 0  1      
  29. NCHOCL010112493      931124  2 Champus was billed.                                                                            
  30. 0DOVBE010112493112493931124  3 11785.2 Heart Murmur            99214     CA65.00          112493            1     5 99A       
  31. 0DOVBE010112493112493931124  3 11785.2 Heart Murmur            93000     CA45.00          112493            1     5 99A       
  32. 0DOVBE010112493112493931124  3 1100000003                      CASH      SA-3.60                            1     5 99A0      
  33. 0DOVBE010112493112493930915  3   Insurance Write-Off           BPWROFF   BA-1.6                             1     0 0  2      
  34. 0DOVBE010112493112493930915  3   Insurance Check #5012         BP        IA    -6.40      112493            1          2      
  35. NDOVBE010112493      931124  3 Medicare was billed.                                                                           
  36. 0DUDST010112393112393931123  2 11783.0 Anorexia                97540     CA30.00          112393            1     6 99A0      
  37. 0DUDST010112393112393931123  2 11Credit Card Payment           CRCDPAY   RA-6.00                            1     6 99A0      
  38. NDUDST010112393      931123  2 CC# 5162008543212300  Exp date: 1094          Name: STEPHANIE DUDE                             
  39. NDUDST010112393      931123  2 John Hancock Insurance was billed.                                                             
  40. 0DUDST010112493112493931020  2   Insurance Check #00225        JH        IA   -48.00                        1          1      
  41. 0ESTPO010112393112393931018  1   Insurance Write-Off           INWROFF   BA-30                              1     0 0  1      
  42. 0ESTPO010112393112393931018  1   Insurance Check #             IN        IA0                    112393      1     0 0  1      
  43. 0FARJA010112293112293931122  6 11346.9 Headache-Migraine       90900     CA40.00          112293            1     5 99A0      
  44. 0FARJA010112293112293931122  6 11Credit Card Payment           CRCDPAY   RA-8.00                            1     5 99A0      
  45. NFARJA010112293      931122  6 CC# 5421002457883131  Exp date: 0294          Name: FARNSWORTH, JANET                          
  46. NFARJA010112293      931122  6 John Hancock Insurance was billed.                                                             
  47. NGONIB010112493      931124  4 Standard Statement was billed.                                                                 
  48. 0GOOHE010112493112493931020  6   Insurance Check #1423         BP        IA   -48.00                        1          1      
  49. 0GOORI010112393112393930915  1   Insurance Check #2147         JH        IA-64                  112393      1     0 0  1      
  50. NGOORI0101123931     930915  1 JH pd. 930915, proc. #74246                                                                    
  51. 0GOORI010112393112393931018  1   Insurance Check #2278         JH        IA   -52.00            112393      1          1      
  52. 0GOORI010112393112393930915  1   Insurance Write-Off           CIGWROFF  BA-30.6                            1     0 0  2      
  53. 0GOORI010112393112393930915  1   Insurance Check #             CIG       IA0                    112393      1     0 0  2      
  54. NGOORI010112393      931123  1 Cigna Health Plan was billed.                                                                  
  55. 0HYNHE010112393112393930913  5   Insurance Write-Off           APWROFF   BA-6.4                             1     0 0  2      
  56. 0HYNHE010112393112393930913  5   Insurance Check #             AP        IA     0.00            112493      1          2      
  57. 0HYNHE010112493112493931020      Medicare Write-Off            MCA        A   -10.00                        1          1      
  58. 0HYNHE010112493112493931020  5   Insurance Check #000452       MP        IA   -20.00            112493      1          1      
  59. NHYNHE010112493      931124  5 Aetna was billed.                                                                              
  60. 0KLICA010112393112393931123  3 11487 Influenza                 99214     CA65.00          112393            1     5 99A       
  61. 0KLICA010112393112393931123  3 1100010000 Copay Cash           COPAYCASH HA-10.00                           1     5 99A0      
  62. NKLICA010112393      931123  3 Cigna Health Plan was billed.                                                                  
  63. 0KLICA010112493112493931020  3   Insurance Write-Off           CIGWROFF  BA-30                              1     0 0  1      
  64. 0KLICA010112493112493931020  3   Insurance Check #             CIG       IA0                    112493      1     0 0  1      
  65. 0MARMA011112493112493931124  4 11959.7 Injury, Toe             99214     CA65             112493            1     5 99A       
  66. 0MARMA011112493112493931124  4 1100000200 Copay Cash           COPAYCASH HA-10.00                           1     5 99A0      
  67. 0MARMA011112493112493931019  4   Insurance Write-Off           INWROFF   BA-50                              1     0 0  1      
  68. 0MARMA011112493112493931019  4   Insurance Check #             IN        IA0              112493112493      1     0 0  1      
  69. NMARMA011112493      931124  4 Intergroup was billed.                                                                         
  70. 0OHAPA011112393112393931018  4   Insurance Write-Off           APWROFF   BA-50                              1     0 0  1      
  71. 0OHAPA011112393112393931018  4   Insurance Check #             AP        IA     0.00                        1          1      
  72. 0RODES010112393112393931123  3 11V221 Pregnancy                99213     CA60.00          112393            1     6 99A       
  73. 0RODES010112393112393931123  3 11V221 Pregnancy                J0210     CA20.00          112393            1     6 99A       
  74. 0RODES010112393112393931123  3 1100010000 Copay Cash           COPAYCASH HA-10.00                           1     6 99A0      
  75. 0RODES010112393112393931018  3   Insurance Write-Off           APWROFF   BA-87                              1     0 0  1      
  76. 0RODES010112393112393931018  3   Insurance Check #             AP        IA     0.00      112393            1          1      
  77. NRODES010112393      931123  3 Aetna was billed.                                                                              
  78. 0SHAIM010112293112293931122  5 11845.00 Sprain Ankle           99214     CA65.00          112293            1     4 99A0      
  79. 0SHAIM010112293112293931122  5 1100010000 Copay Cash           COPAYCASH HA-10.00                           1     4 99A0      
  80. NSHAIM010112293      931122  5 Intergroup was billed.                                                                         
  81. 0SHAIM010112493112493931020  5   Insurance Write-Off           INWROFF   BA-85                              1     0 0  1      
  82. 0SHAIM010112493112493931020  5   Insurance Check #             IN        IA0                                1     0 0  1      
  83. 0YOUMI010112293112293931122  3 11401.9 Hypertension            99212     CA40.00          112293            1     6 99A0      
  84. 0YOUMI010112293112293931122  3 1100000103 Cash                 CASH      SA-8.00                            1     6 99A0      
  85. NYOUMI010112293      931122  3 Champ VA was billed.                                                                           
  86. 0YOUMI010112493112493931020  3   Insurance Check #6001         CHV       IA-52                              1     0 0  1      
  87.