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    Superbill Johndoe

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    Superbill Johndoe

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    superbill johndoe

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    3K views1 page

    Superbill Johndoe

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    api-295063762

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    © All Rights Reserved
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    of 1

    Ric Valentine Acupuncture

    17812 Moro Road, Prunedale CA 93907 (o) 831-663-0444 (f) 831-663-2444 (e) ric@ricvalentineacupuncture.com

    SuperBill

    1/21/2017

    Patient: John P. Doe

    Patient DOB:

    Patient Signature:
    With my signature I authorize the release of any information requested to process this claim

    Visit Date ICD 10 CPT Code Charges


    1/21/2017 M54.42 97810 $45.00
    1/21/2017 M54.42 97811 $20.00

    Total: $65.00

    Richard "Ric" Valentine L.Ac.


    NPI 1710146279
    LAC # AC4200

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