BILLING ADDRESS: 1600 S FEDERAL HWY.

SUITE 811
POMPANO BEACH, FL 33062
PH 754-205-6865 FAX 754-206-1958
TAX ID: 20-0805089 / NPI: 1205260965 / FLORIDA BLUE PROVIDER #Z0VSA

OFFICE: ____ Aventura _____ Coral Springs ____ Ft Lauderdale

____ Lake Worth _____ Plantation _____ Pompano _____Weston

PATIENT ___________________________________________________

DOB______________________________

INSURANCE COMPANY: AETNA ID# ______________________

EFFECTIVE DATE _____________________

IN NETWORK:

INDIV DED: $ AMT MET: $ OUT OF POCKET: $ AMT MET: $

FAMILY DED: $ AMT MET: $ OUT OF POCKET: $ AMT MET: $

COPAY: $ POLICY PAYS: % # OF ADJ PER YR: # USED:

DOES DEDUCTIBLE APPLY FOR

99203 ___Y ___ N 97110 ___ Y ___ N 72100 ___ Y ___ N
98941 ___Y ___ N 72050 ___ Y ___ N

ADDITIONAL COMMENTS:

VERIFIED BY AETNA 1-888-632-3862

REP NAME_____________________________

CALL REFERENCE # _____________________

DATE _________________ COMPLETED BY ___________________