Appt Date                   Appt Time                     Category                        Appt Type                     Referring Dr                                                                             Superbill#

Account #                   Patient Name                                                                                        Sex               Birthdate                                      Home Phone

Address

Primary Insurance                                                                                                   Copay              Secondary Insurance

Employer                                                                                                                                  Work Phone

Today’s Charges

Today’s Payments

Notes                                                                                                                                                                                         Cash        Check        Debit Card       Credit Card

Current

Over 30 Days

Over 60 Days

Over 90 Days

Patient Balance

Total Balance

SECTION HEADING

CPT code   Description

DIAGNOSIS

ICD 10 Code   Description

Comments Special Instructions:  

Doctor’s Signature/Date :

Return Appt:

Days:_______     Weeks: _______

Months:  _______