SERVICE PLAN ID: 0097987987

APPOINTMENT ID: 0076783

PATIENT NAME: Carl, Jason

MRN: 007867

Service Plan status

Individual/Family

Payor Code 00834245-SWE007886768

Payor Name Aetna

Eligibility Check

Service Item Group Therapy - Rehabilitation

Duration in Minutes 30

Visits 1

Total Units

3

Delivery Method

Face-2 face

Recipient Code

Cons, Coll, Waiv Pro

Place of Service

Bursing Home

Address

678 Tallassee,FL

Axis

Axis	Description	Primary / Secondary
Axis I	Anxiety

Diagnosis

Type	Code	Description	Delete
ICD-9	311	Mild Depression (Disorder)

Procedures

Code	Description	Units	Charges	Amount	Delete
90820	Psychotheraphy 30 Minutes		$125.00	$375.00

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