Sample Professional Print Image

  Note:

                                   TX MEDICARE PART B@00900                   3
                                   P.O. BOX 660031                            3
                                   DALLAS TX  75266-0031                      3
                                                                              3
                                                                              3
                                                                              3
                                                                              3
 X                                               W123456789                   3
                                                                              3
 DOE     JOHN                  01 01 1900 X      DOE     JOHN                 3
                                                                              3
 2323 NEVER NEVER LAND           X               2323 NEVER NEVER LAND        3
                                                                              3
 SOUTHPARK                 TX      X             SOUTHPARK                TX  3
                                                                              3
 77777        123 456-7890                       77777          123 456-7890  3
                                                                              3
 SAME                                            NONE                         3
                                                                              3
 NONE                                    X                                    3
                                                                              3
  01 01 1900      X                      X       MICROFOUR INC                3
                                                                              3
 MICROFOUR INC                           X       MEDICARE                     3
                                                                              3
 MEDICAID                                                                     3
                                                                              3
                                                                              3
      SIGNATURE ON FILE             020808       SIGNATURE ON FILE            3
                                                                              3
                                                                              3
  01 29 2008                          01 29 2008                              3
                              XX12345                                         3
 DOE JOHN                     1234567890                                      3
                                                                              3
 CORRECTED CLAIM                                         X                    3
                                                                              3
   250.02                    272.2                                            3
                                                                              3
   401.1                     530.81                                           3
                                                                              3
                                                                              3
                                                                   XX12345    3
 02 08 08   02 08 08   11    99214            1      135 00   1 N  1234567890 3
                                                                   XX12345    3
 02 08 08   02 08 08   11    36415            1       20 00   1 N  1234567890 3
                                                                   XX12345    3
 02 08 08   02 08 08   11    17000            1      100 00   1 N  1234567890 3
                                                                              3
                                                                              3
                                                                              3
                                                                              3
                                                                              3
                                                                              3
                                                                              3
 12-3456789        X  DEMO-029652    X                255 00                  3
                                                                 123-456-7890 3
                       QUEST DIAGNOSTICS LABORATOR DOE HEALTH                 3
                       4770 REGENT BOULEVARD       1235 E.NEVERLAND RD,STE 1003
 DOE  JOHN, D.O.       IRVING TX  75063            ANYWHERE, TX 75081         3
            02082008                               1234567890   00527K        3
                                                                              3
                                   TX MEDICAID FISCAL AGENTS @869             3
                                   EDS/NHIC                                   3
                                   P.O. BOX 200555                            3
                                   AUSTIN TX  787200555                       3
                                                                              3
                                                                              3
                                                                              3
        X                                        123456789                    3
                                                                              3
 DEMO    JOHN                  01 01 1900 X      DEMOGUY JOHN                 3
                                                                              3
 2323 NEVER NEVER LAND           X               2323 NEVER NEVER LAND        3
                                                                              3
 SOUTHPARK                 TX      X             SOUTHPARK                TX  3
                                                                              3
 77777         123 456-7890                      77777          123 456-7890  3
                                                                              3
 DEMO    JOHN                                    NONE                         3
                                                                              3
 NONE                                    X            01 01 1900    X         3
                                                                              3
 11 01 1900      X                      X       MICROFOUR INC                 3
                                                                              3
 MICROFOUR INC                           X       MEDICAID                     3
                                                                              3
 MEDICARE                                           X                         3
                                                                              3
                                                                              3
      SIGNATURE ON FILE             020808           SIGNATURE ON FILE        3
                                                                              3
                                                                              3
  01 29 2008                          01 29 2008                              3
                              XX12345                                         3
 DOE JOHN                     1234567890                                      3
                                                                              3
 CORRECTED CLAIM                                         X                    3
                                                                              3
   250.02                    272.2                                            3
                                                                              3
   401.1                     530.81                                           3
                                                                              3
                                                                              3
                                                                   XX12345    3
 02 08 08   02 08 08   11    99214            1      135 00   1 N  1234567890 3
                                                                   XX12345    3
 02 08 08   02 08 08   11    36415            1       20 00   1 N  1234567890 3
                                                                   XX12345    3
 02 08 08   02 08 08   11    17000            1      100 00   1 N  1234567890 3
                                                                              3
                                                                              3
                                                                              3
                                                                              3
                                                                              3
                                                                              3
                                                                              3
 12-3456789        X  DEMO-012345    X                255 00                  3
                                                                 123-456-7890 3
                       QUEST DIAGNOSTICS LABORATOR DOE HEALTH P.A.            3
                       4770 REGENT BOULEVARD       12345 NOWHERE RD           3
 DOE JOHN, D.O.        IRVING TX  75063            ANYTOWN, TX 75081          3
            02082008                               1234567890      12-234567893
                                                                              3
                                   TX BCBS@84980                              3
                                   P.O. BOX 660044                            3
                                   DALLAS TX  752660044                       3
                                                                              3
                                                                              3
                                                                              3
                                                                              3
                                             X   123456789                    3
                                                                              3
 DEMOGUY JOHN                  11 25 1986 X      DEMOGUY JOHN                 3
                                                                              3
 2323 NEVER NEVER LAND           X               2323 NEVER NEVER LAND        3
                                                                              3
 SOUTHPARK                 TX      X             SOUTHPARK                TX  3
                                                                              3
 77777         123 456-7890                      77777          123 456-7890  3
                                                                              3
                                                 12355                        3
                                                                              3
                                         X            11 25 1986    X         3
                                                                              3
                                         X       MICROFOUR INC                3
                                                                              3
                                         X       BCBS                         3
                                                                              3
                                                         X                    3
                                                                              3
                                                                              3
      SIGNATURE ON FILE             020808           SIGNATURE ON FILE        3
                                                                              3
                                                                              3
  02 08 2008                          02 08 2008                              3
                              G8G80552                                        3
 DOE JOHN                     1234567890                                      3
                                                                              3
                                                         X                    3
                                                                              3
   354.0                                                                      3
                                                                              3
                                                 123546791                    3
                                                                              3
                                                                              3
                                                                   XX12345    3
 02 08 08   02 08 08   11    95903            1      330 00   3 N  1234567890 3
                                                                   XX12345    3
 02 08 08   02 08 08   11    95904            1      360 00   4 N  1234567890 3
                                                                              3
                                                                              3
                                                                              3
                                                                              3
                                                                              3
                                                                              3
                                                                              3
                                                                              3
                                                                              3
 12-3456789        X  DEMO-029654    X                690 00                  3
                                                                 123-456-7890 3
                       QUEST DIAGNOSTICS LABORATOR DOE HEALTH SYSTEM          3
                       4770 REGENT BOULEVARD       12345 ANY ROAD, STE 100    3
 JOHN DOE, D.O.        IRVING TX  75063            ANYTOWN, TX 75081          3
            02082008                               1234567890   XX12345       3