Corporate Health Management - Flu shots and vaccinations in Dallas, Texas

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

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

Click here for printable version, only if you want to complete form by hand. Otherwise, fill in the blanks on this screen and print.

CASH SALES RECEIPT

Name of Patient:

Date of Procedure:

DOB:

SS#:

Physician: J. Paul Sanders, M.D.

$ Amount Paid:

	Vaccine(s)	ICD-9 Code	CPT Code

	Influenza 0.5 ml	V04.80	90658
	Pneumovax	V03.83	90732
	Tetanus/Diphtheria 0.5 ml	V06.50	90718
	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 by the patient stated above.

PLEASE SEND REIMBURSEMENT CHECK TO THE ADDRESS BELOW: