Genius Solutions, Inc. - Encounter Form / Superbill Sample GENIUS SOLUTIONS, INC. 5504 E. 12 MILE RD STE B WARREN, MI 48092-4637 APPT. INFO. PATIENT INFORMATION ANDERSON, ARIAL T OCTOBER 22, 1999 1234 MAIN 08:20A CLINTON TWP, MI 48038 OV OFFICE VISIT H:248-362-6810 W:810-555-5545 SN:999-99-9999 DOB:05/16/1966 POLICY HOLDER 01 MARILYNN BROWN MD NOTES CASH: INSURANCE: 778.00 GR:25000 GENIUS SOLUTIONS, INC. GR:12345 5504 E. 12 MILE RD. STE B WARREN, MI 48092 REF. PHYSICIAN MARK THUEMMEL MD PATIENT HAS A PAYMENT PLAN - LAST XRAY:09/23/2000 EST. PATIENT EXAMS 99211 5 MINUTES 99212 10 MINUTES 99213 15 MINUTES 99214 25 MINUTES √ NEW PATIENT EXAMS 99201 10 MINUTES 99202 20 MINUTES 99203 30 MINUTES √ ADJUSTMENTS 97140 ADJUSTMENT 98940 CMT 1 – 2 98941 CMT 3 – 4 98942 CMT 5 THERAPY 97010 HOT/COLD PACKS 97012 MECHANICAL TRACTION 97110 THERAPEUTIC EXERCISES 97112 NEUROMUSCULAR RE-ED 97124 MASSAGE 97530 THERAPEUTIC ACTIVITIES 97799 THERAPY UNLISTED CODE √ X – RAYS 72010 FULL SERIES 72040 CERVICAL 2 VIEWS 72050 CERVICAL 4 VIEWS 72052 CERVICAL 6 VIEWS 72070 THORACIC 2 VIEWS 72100 LUMBAR 2 VIEWS 72110 LUMBER 4 VIEWS 72170 PELVIC 76499 X-RAY ANALYSIS SUPPLIES TODAY’S PAYMENT BALANCE DUE FIXRATE:(10/19/2000 – 10/18/2001) LAST VISIT:10/14/2000 √ √ ADJUSTMENT 40.00 EMPLOYER MR MEDICARE PART B FIELD MAX (MR) PO#:999-99-9999 BC/NY BLUE CROSS BLUE SHEILD NY (BC) PO#:XYZ999-99-9999 PROVIDER TODAY’S CHARGES BALANCE Acct No:00002700 The entire top portion of the form can be customized for the office name, address or other relevant office information. The information section will be completed by your THOMAS software each time an encounter form is requested. Genius Solutions will design the lower portion of the encounter form to contain services and information required by your individual office. SUPPLEMENTS For pricing and information, please contact Genius Solutions (586) 751-9080. Route Slip Ordering Procedure: All route slip orders must follow the guidelines below in order that it can be produced in the most efficient way. Sections should be in the order as they should appear on form Numerical and alphabetical order All caps, upper, or lower case as they should appear on form Typed or hand printed copy Pricing for a one-time type setting fee applied to all new first-time orders: Light to Medium composition $ 50.00 per page (One revision at no charge after type setting) Heavy composition $ 75.00 per page Changes to original first order will be $15.00 per each change Standard ink color: Black Single color available in Blue, Green, Red, and Burgundy for an additional charge of $10.00. Turn around time on art services varies by job but will typically take 4 to 5 days. Production time 5-10 business days after art approval. Standard over/under run is 10%. All artwork done without order within 30 days will be billed accordingly; prices are subject to change without notice.