D CIAL CONTROLS N T-EN N SCHEDULING A eaccess O NI R F F BILLING

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3 FRONT-END FINANCIAL CONTROLS eaccess SCHEDULING BILLING

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6 Injection Administration intramuscular Proliferative Les. -Less than 10 sq cm any area: up to and including 15 lesions (e.g. Condyloma, papelloma, molluscum, contagiosum, herpatic vesicls, simple chemical) DESTRUCTION, MALIGNANT LESIONS, ANY METHOD Next Appointment Days Weeks Months ADJACENT TISSUE TRANSFER OR RE-ARRANGEMENT I hereby authorize the release of medical information to insurance carriers concerning my illness and treatment and I hereby assign to the doctor all payments for medical services rendered to my dependent. I understand I AM RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY INSURANCE. Patient/Responsible Party Malig Destruction Trunk, Arms and Legs Trunk, Arms and Legs Trunk, Arms and Legs Test Scalp, Neck, Hands, Feet Scalp, Neck, Hands, Feet Scalp, Neck, Hands, Feet Face, Ears,Nose, Lips Face, Ears,Nose, Lips Face, Ears,Nose, Lips understand I AM RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY INSURANCE. Phone: NPI: Test Fax: Tax ID: 48 McKinney Rd John Feelgood, D.O. Date Pt # Patient DOB Phone: SSN Resource Reason Follow-Up 07/07/10 11:00 AM Doe, John C 1/1/1980 Fax: Goodwrench Dx # Recent Dx's Today's Dx Ins Name Primary Care Provider Prior Balance HYPERTENSION NOS Medicare Date Pt # Patient AARP Health Care Options OCL CRTD ART WO INFRC 1 Today's Charge 07/05/10 04:15 PM Required, Etst Hypertension NOS Prior Auth # 48 McKinney Rd DOB SSN Resource 1/1/ Goodwrench HYPERTENSION NOS 2 Dx # Recent Dx's Today's Dx Ins Name 496 Chr airway obstruct NEC Guarantor: Doe Invalid Address Today's Payment PO Box HYPERTENSION NOS Invalid Phone 460 Acute nasopharyngitis Ocl crtd art wo infrct Phone: Cash Check Credit JOHN@MYNETWORK.COM Prior Auth # Malig neo skin trunk 4 2 NEW PATIENT CPT INJECTIONS CPT DESTR., MAL., LES., ANY METH. CPT REPAIR - COMPLEX (cont) CPT Guarantor: Responsible Party for: E & M I Clindanycin 300 mg S0077 Scalp, Neck, Hands, Feet, Genitalia Over 7.5 cm Attn: Etst Required E & M II Kenalog (10 mg per Unit) J cm or less 17270* REPAIR - INTERMEDIATE 3 Test E & M III Bleomycin J to 1.0 cm Scalp, Axillae, Trunk, Arms and Legs E & M IV Rocephin 250 mg J to 2.0 cm Up to 2.5 cm 12031* E & M V Celestone 4 mg J to 3.0 cm cm 12032* Phone: ESTABLISHED Methotrexate J to 4.0 cm Neck, Hands, Feet, Ext Genitalia E & M I DESTRUCTION Over 4.0 cm Up to 2.5 cm 12041* E & M II BENIGN OR PREMALIGNANT LESIONS Face, Ears, Eyelids, DESCRIPTION Nose, Lips, Mucous MembraneCPT cm CPT 12042* DESCRIPTION CPT E & M III Destruction by any method - 1st Les cm or less OFFICE (NEW) 17280* New Face, Ears, Established Eyelids, Nose, Lips, Mucous Mem. OFFICE LABS E & M IV nd through 14th lesions to 1.0 cm E & M I Up to 2.5 cm * Lab Handling Fee E & M V Destruction by any method to 2.0 cm cm 12052* E & M II Glucose * Surgical Follow Up 99024, NC 15 or more lesions 2.1 to 3.0 cm cm E & M III Helicobacter Pylon * OFFICE CONSULATIONS Destruct. of Cutaneous Vascular to 4.0 cm Office Consult. 15 min Over 4.0 cm E & M IV Trunk Hemoglobin Office Consult. 30 min sq cm EXCISIONE & M V BENIGN MALIG sq cm or less KOH Slide Office Consult. 40 min Over 50.0 sq cm Smoking Trunk, Cecceastion Arms, and - Legs 3-10 mins Defect 10.1 sq cm sq cm Pap Smear (Conventional) Office Consult. 50 min Destruct. by any method - Flat Warts cm or less Smoking Cesseastion Over min Scalp, Arms, LegsPap Smear (Thin Prep) Office Consult. 60 min Molluscum, Contagiosum, or Milia up 0.6 to 1.0 cm Follow-Up sq cm or less PPD BIOPSY to 14 Lesions 1.1 to 2.0 cm PREVENTATIVE New Defect 10.1 sq Established cm sq cm PT (INR) Biopsy of Skin, Single Lesion or more Lesions to 3.0 cm Infant, under age Forehead, Cheeks, 99391Chin, Mouth, Rapid Neck, Axillae, Strep Screen Biopsy, ea. Sep./Add Lesion REMOVAL OF SKIN TAGS 3.1 to 4.0 cm Genitalia, Hands and/or Feet Ages Stool Occult Biopsy of Lip Multiple fibrocutaneous tags, 11200* Over 4.0 cm sq cm or less Ages Stool Occult - Mcare Scrn Only G0394 Biopsy of Tongue Scalp. Neck, Hands, Feet, Genitalia Defect 10.1 sq cm sq cm anterior, posterior, or one-third Each additional 10 lesions cm or less Ages Eyelids, Nose, Ears and/or Urinalysis Lips dipstick Biopsy of Floor of Mouth DESTRUCTION OF LESIONS 0.6 to 1.0 cm Ages sq cm or less Urinalysis w/microscopy Biopsy of Penis Destruction of Lesions, Anus 46900* 1.1 to 2.0 cm Ages Defect 10.1 sq cm sq cm Urinalysis dipstick, automated Biopsy of Vaginal mucosa/simple 57100* 2.1 to 3.0 cm 65 and over OTHER PROCEDURES AND Flu SUPPLIES test Biopsy of Eyelid 67810* 3.1 to 4.0 cm Welcome to Medicare PX Patch Test (1-29) G0402 Urine Pregnancy Biopsy, external Ear Over 4.0 cm Welcome to Medicare EKG PX Sclerotherapy/Spider G0403 Veins Urine Microalbumin INCISION & DRAINAGE Electrodesiccation 46910* Face, Tracing Ears, Interp Eyelids, & Report Nose, and Lips Unna Boot Application G0404 Venipuncture Acne Surgery, Opening Removal 10040* Cryosurgery cm or less Unna Boot Removal IMMUNIZATIONS/INJECTION ADMINISTRATION Wet Mount (includes KOH) Abscess, Cyst 10060* Laser Surgery to 1.0 cm SHAVINGS OF EPIDERMAL OR DERMAL LESIONS Drainage/Simple or Single Any Method to 2.0 cm Immunization Administration Single Trunk, Arms, Legs Abscess, Complicated or Multiple Penis 54050* 2.1 to 3.0 cm Immunization Administration each additional 0.5 cm or less LABORATORY Electrodesiccation 54055* 3.1 to 4.0 cm Influenza to 1.0 cm G Pathology - Direct Immuno Flu Cryosurgery Over 4.0 cm Pneumonia to 2.0 cm G Pathology - Surgical Extensive, Any Method REPAIR - COMPLEX INJECTIONS Over 2.0 cm 11303OUTSIDE LABS **DO NOT BILL-INFORMATION ONLY** Venipuncture Destruction of Lesion of Lid margin Therapeutic Trunk Injection - Administration Scalp, Neck, Hands, Feet, Genitalia NAILS up to 1 cm cm DRUG NAME CPT 0.5 cm or QTY less NDC # Avulsion Nail, Single, Simple cm Benadryl J to 1.0 cm Each additional Nail unit Trunk, Arms, or Legs Scalp, Arms, Legs 1.1 to 2.0 cm Bicillin LA up to 600,000 units J0560 Matrixectomy cm or less cm Over 2.0 cm Biopsy of Nail unit to 1.0 cm cm Bicillin LA up to 1.2 mil units J0570 Face, Ears, Eyelids, Nose, Lips, Mucous Membrane UV TREATMENT 1.1 to 2.0 cm Forehead, Depo-Medrol Cheeks, Chin, 40 mg Mouth, Neck, Axillae J cm or less Photochemotherapy TAR & UVB to 3.0 cm Hands Methylprednisolone and/or Feet, Genitalia acetate 0.6 to 1.0 cm INJECTIONS 3.1 to 4.0 cm cmdepo-provera 150 mg J to 2.0 cm Over 4.0 cm cmdexamethasone (Decadron) J1100 Over 2.0 cm SKIN EXCISIONS/DESTRUCTIONS Injection, intralesional 11900* DHE Eyelids, 1 mg Nose, Ears, Lips J1110 Benign Excision up to and including 7 lesions Up to 1.0 cm Epinephrine up to 1 ml J cm or less more than 7 lesions 11901* cm Imitrex up to 5 mg J cm Cefazolin 500 mg J cm Insulin up to 100 units J cm Kenalog per 10 mg J cm Lasix up to 20 mg J cm Phenergan up to 25 mg J2550 Over 4.0 cm Rocephin up to 1 gram J0696 Malig. Excision Solumedrol up to 40 mg J cm or less Appt ID: 5751 Last GFP VIsit: 7/1/ :00:00 AM Monday, July 12, :40 PM Solumedrol up to 125 mg J cm Pending Insurance: $ Within Global Period Toradol up to 60 mg J cm Vitamin B12 up to 1000 mcg J cm Mirena IUD J cm Provider: Paragard IUD J7300 Over 4.0 cm cm or less cm cm cm cm Over 4.0 cm NPI: Tax ID: John Feelgood, MD Reason Normal Primary Care Provider Prior Balance $ Today's Charge Invalid Address Today's Payment Invalid Phone Cash Check Credit DESCRIPTION CPT PROCEDURES - SKIN Biopsy 1st Lesion Biopsy ea add'l Lesion Skin Tag Removal up to Skin Tag Removal (each add'l 10) Destruction - Benign/Premalignant (AK's & Warts except flat) 1st Lesion nd - 14th Lesion or more Lesions Warts/Benign Lesion or more Warts PROCEDURES - ORTHO Inject. Tr Point Tendon, Ligament Inject/Asp. - Small Inject/Asp. - Intermediate Inject/Asp. - Major Inject/Asp. - Gang. Cysts PROCEDURES - GU Endometrial Biopsy IUD Insertion IUD Removal PROCEDURES - EENT Audiometry Ear Lavage Tympanometry PROCEDURES-CARDIO-PULMONARY EKG - complete EKG - tracing only EKG - interpretation & report only Nebulizer Treatment PFT's PFT's Before & After Bronch or Exercise OTHER Fine Needle Aspiration Excision, nail plate Toenail removal Acne Surgery Shaving Lesions 113 Repair - Simple 120 Repair - Intermediate 120 Repair - Complex 131 Incision & Drainage 10 Excision/Debrid. 110 Paring/Cutting 1105_ Burns 160 SPECIAL PERFORMANCE MEASURES All scripts sent with e-prescribe system G8443 No scripts sent with e-prescribe system G8445 Scripts phoned in or printed G Appt ID: 5743 Last GFP VIsit: Monday, July 12, :28 PM Pending Insurance: Within Global Period I hereby authorize the release of medical information to insurance carriers concerning my illness and treatment and I hereby assign to the doctor all payments for medical services rendered to my dependent. I Provider: Next Appointment Days Weeks Months Patient/Responsible Party

7 999 Patient Information First Feelgood Medical Associates P.O. Box McKinney Rd Patient Demographic Profile Middle Last Suffix John 05 July 2010 SSN: Monday Alt Last Name: Lab 7AM Guarantor Information Guarantor First Name C Doe Feelgood Medical Associates DOB: 01/01/1980 Sex: M MBA Test Site1 Alt First Name: Goodwrench Middle Last Suffix Doe Feelgood Medical Associates Addr 1: PO Box 1479 Addr2: City: Etowah St: NC Zip: Drew, Nancy (H#: Guar SSN: Cricket, Jiminy (MBA Test 8:00 AM-8:40 Guar AM DOB: Doe, Joe 03/05/2009 (H#: ) (MBA Test 8 00 Guar Sex: 5545) (MBA Test Site1) Site1) Site1) Home#: MBA Test Site1 Home#: Required, a (MBA Test Site1) Home #: Work #: Cell #: Work#: Lab JOHN@MYNETWORK.COM Secondary Ins = BCBS NC Delivery By: Monday, July 05, 2010 Guarantor Employer Info Fudd, Elmer Employer (H#: ) Name: (MBA MBA Test Site1) 08:00 AM Drew, Nancy (05/05/2005) Scheduled Home#: Home#: :00 AM Cricket, Jiminy A (05/01/1950) Scheduled Addr No 1: Insurnace PO Box 1479 Addr 2: Mouse, Micky (H#: ) (MBA Test Site1) 9 00 Home#: City: Etowah St: NC Zip: Fasting Labs Insurance Information 08:15 AM Required, a b (11/01/2006) Scheduled 01:00 PM Doe, John C (01/01/1980) Scheduled Insurance Primary Company Ins = Medicare Reln Effective Subscriber Name PCP NPI Group # Subscriber # Medicare Secondary Ins = AARP Self Health Care 01/01/2008 Options Doe, John C B Cigna, Inc. PO Box 671 Goodwrench Nashville, TN AARP Health Care Options Spouse 01/01/2008 Day, Love (MBA Doe, Test Jane Site1) C Monday, July 05, United Healthcare Ins Co PO Box Atlanta, GA :00 AM Doe, Joe (01/01/1970) Scheduled Home#: None Work#: Secondary Ins = BCBS NC 08:45 AM Fudd, Elmer (12/10/1950) Scheduled Home#: :00 AM Mouse, Micky (01/01/1960) Scheduled Home#: :00 AM Day, Love Swift, Steve (MBA Test Site1) 11 (02/14/1967) 00 Scheduled Guarantor Signature: Date: 11:00 AM Swift, Steve (05/25/1970) Scheduled 01:00 PM Gry, J D (01/01/1980) Scheduled Home#: Internal Use Only Entry Date Last Updated DOD Discharged AA Bill 01:15 PM Test, Medicaid Test Scheduled Primary Ins = Medicaid 11/15/06 11:02 04/07/10 15:34 2 True True (01/01/2000) 02:00 PM Dirt, Joe (01/01/1970) Scheduled Monday, Home#: July 12, :44 PM 03:00 PM Required, P R (11/01/2000) Scheduled 03:30 PM Required, P M (09/01/2007) Scheduled ResourceUnavailable (Test) Secondary Ins = Medicaid ResourceUnavailable (Test) 12PM 04:00 PM Streets, Windy (01/01/1965) Lunch Scheduled Lunch 04:15 PM Required, Etst (01/01/2008) Scheduled $ [02] Pete M July 12, :51:40 PM 1/ /12/2010 2:51 PM 1/1

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