Corporate Health Management
7515 Greenville Avenue, Suite 600
Dallas, Texas 75231

(214) 361-0995
(214) 361-0865 FAX
Tax ID #: 75-2430306

CASH SALES RECEIPT

Click here for a printable version of the flu receipt.

Name of Patient:

 

 

Date of Procedure:

DOB:

  

SS#

 

Physician: J. Paul Sanders, M.D.

  

$ Amount Paid:

 
  Vaccine(s) ICD-9 Code CPT Code

 

 Influenze 0.5 ml V04.81 90658

 

 H1N1 Influenza 0.5 ml V04.81 90658

 

 Tetanus/Diphtheria 0.5 ml V06.50 90718

 

 Pneumovax V03.83 90732

 

 Hepatitis A 1.0 ml V05.3 90632

 

 Hepatitis B 1.0 ml V05.3 90746

 

 Zostavax V04.89 90736
Note: The vaccine(s) marked above have been paid in full for by the patient stated above.

PLEASE SEND REIMBURSEMENT CHECK TO THE ADDRESS BELOW:

 

 

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