KMHM DAILY CHARGE SHEET

Page 1 of 22 - PATIENT CHARGE LINE #1

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PATIENT CHARGE LINE #1
Provider Selection
Date of Serivce Date of Serivce / MM / DD YYYY
Patient Name Patient Name First Last
Billing Code
MODIFIER
UNITS
SES #
DX 1
DX 2
DX 3
DX 4
INSURANCE 1

PLEASE SELECT INSURANCE FROM LIST
IF INSURANCE IS NOT ON LIST SELECT OTHER AND INDICATE INSURANCE IN NOTES AREA BELOW
INSURANCE 2
INSURANCE 3
COPAY AMOUNT

IF N/A IS SELECTED THEN ENTER ZERO (0.00) IN THIS FIELD.
COPAY TYPE

COPAY TYPE CASH CREDIT CARD N/A CHECK NUMBER CHECK NUMBER

IF CHECK IS SELECTED, PLEASE ENTER CHECK NUMBER IN BOX BELOW
NOTES

*USE THIS AREA TO INDICATE ANY RELATED INFO NEEDED FOR THIS SESSION.

*IF OTHER INSURANCE IS CHECKED, ENTER NAME HERE AS WELL.
IS THIS THE ONLY PATIENT TO ENTER?

PLEASE INDICATE IF THIS IS THE LAST PATIENT THAT WAS ON THIS DAILY SHEET