J. SKLAR MEDICAL BILLING SVC New York MEDI-CAII 1D Ciaim Form + P.O. BOX 340 + Valley Stream, NY 11582 + 516-791-5630 + wow JSKLAR.COM OPTICALBILLING@GMAIL MEDIC-AID PROVIDER # or NPL PATIENT: LAST NAME: LD. # PROVIDER NAME: me ‘COMMENTY HMO NAME: Replacement Glasses) EXAMINATION CODES: CIRCLE CODES FOR SERVICES RENDERED: oxreorseavce CJ OOOO 192002. INTERMED. EXAM - tiie! A 2012 INTERMED. EXAM - Subsequent (after 2s) 2 92004 COMPR, EXAM - Initial 92014 COMPR. EXAM- Subsequent (after 2yr5) ss a2 99212. FOLLOW UP EXAM Dx. # » 92230 FUNDUS PHOTOS 48 99213 FOLLOW UP EXAM Dx. ft 192202 OPHTHALMOScOPY a __99214 FOLLOW UP EXAM Dx. # 92081 92082 92083 VISUAL FIELDS-Ievel | /level 2/level 3 SINGLE VISION: ‘SPHERES 8 _¥2100__PL- 4.00 7 V2101__4.25-7.00 2102 _7.25-20.00 ss V2103__ PL 200CYL f V2107 _ 4.25-7.00= PL 2.00 V2 __7.25- 12.00 is V2104__ 254.00 ‘V2108 __ 4.25 - 7.00 = 2.25 - 4.00 2112 __725- 12.00 BIFOCALS! ‘SPHERES 3 ¥2200___ PL -4.00 we V2201_4.25-7.00 v2202_7.25- 20.00 ‘COMPOUNDS 44 V2203__ PL -4.00= PL -2.00 16 V2207__ 4.25-7.00= PL -2.00 ‘V2211_725-12.00= PL -2.00 8 V2204__ PL 4.00=2.25-4.00 v2208 4.25 - 7.00 = 2.25 - 4.00 V2212_7.25- 12,00 = 2.25-4.00 DISPENSING SERVICES AND MATERIALS 2: Dis (SEBIFOCAL -n V2220__ ADD > 3.25 PATIENT: LAST NAME: CCOMMENT/ HMO NAME: LD. ‘| é E] von:| [| Hace Gases) pareorsexvice []] I EXAMINATION CODES: ciReLE CODES FoR seAVCrS RENDERED Fee Sains INTERMED, EXAM = Dial (92012 INTERMED. EXAM - Subsequent (afier2yrs) 2 92004 COMPR, EXAM - Initial 2 92014 COMPR. EXAM- Subsequent (after 2yrs) se 99212 FOLLOW UP EXAM Dx. # Pp __ 92250 FUNDUS PHOTOS of) 99215 KULLOW UP EXAM Dx. 1 yzuz—_rHtitaLmuscory sf 99214 FOLLOW UPEXAM Dx. # 8 __ 92081 92082 92083 VISUAL FIELDS-level 1 / level 2/level 3 [SINGLE VISION: ‘SPHERES 8 _V2100__PL- 4.00 7 Y2101__ 4.25 -7.00 y2i02__ 7.25. 20.00 ‘COMPOUNDS fs V2103__ PL-4.00= PL- 200CYL f V2107 __425-7.00= PL- 2.00 Y2i11__725-12,00= PL-2.00 fs V2108__ PL-4.00=2.25 - 400 y2108 __ 4.25 -7.00, 4.00 yaul2__ 725-12, 4.00 [BIFOCALS: SPHERES ss V2200_ PL.-4.00 a V2201__4.25-7.00 2202 _725-20.00 ‘COMPOUNDS V2205__ PL-4.00=PL-200 fe V2207__ 423-1.K)= PL -200 Vz 725-1200 PL -200 1s V2204__ PL-4.00=2.25-4.00 V2208__ 4.25 -7.00 = 2.25 - 4.00 y2212_7.25-12,00=2.25 - 4.00 DISPENSING SERVICES AND MATERIALS ¥ V20200___ FRAME.» 92340___DISPENSES.V, _-» 92341 _ DISPENSE BIFOCAL 0 V2220 _ ADD> 3.25 aP S0S80__ POLYCARB + 92370__REPAIR OTHER OTHER, ai