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| Field Name | Value |
|---|---|
| Patient Name | John Doe |
| Date of Birth | January 15, 1980 |
| Gender | Male |
| Address | 456 Oak Avenue, Cityville, State, Zip |
| Phone Number | (555) 123-4567 |
| xyzclinic@email.com | |
| Insurance Policy Number | ABC123456 |
| Group Number | G98765 |
| Provider Name | XYZ Medical Clinic |
| National Provider Identifier (NPI) | 1234567890 |
| Fax Number | (555) 123-4568 |
| Date of Service | March 1, 2023 |
| Description of Service/Procedure | Office Consultation |
| Diagnosis Code (ICD-10) | M10.9 (Osteoarthritis, unspecified) |
| Procedure Code (CPT) | 99213 (Office or other outpatient visit for the evaluation and management of an established patient, moderate severity. |
| Consultation Fee | $100.00 |
| Procedures/Services | $0.00 (Only consultation performed) |
| Medications | $30.00 (Prescription for pain relievers) |
| Other Charges (specify) | $0.00 |
| Total Amount Claimed | $130.00 |
| Prescription details | Acetaminophen 500mg, 30 tablets. |
| Signature | Dr. Jane Smith, MD |
| Date | March 15, 2023 |