Billing for Non$-$Emergency Hospital Visits

Assignment #$4-$ Module D$2$

Date:

Student Name: $\begin{array}{cc}\text{P}\text{h}\text{y}\text{s}\text{i}\text{c}\text{i}\text{a}\text{n}\text{N}\text{a}\text{m}\text{e}& \text{P}\text{h}\text{y}\text{s}\text{i}\text{c}\text{i}\text{a}\text{n}\text{N}\text{u}\text{m}\text{b}\text{e}\text{r}\\ ?& ?\end{array}$

$\backslash$table$[[$Last Name,First Name,Date of Birth $($YYYMMDD$),$Health #$,$Version$],[,,,,]]$

$\backslash$table$[[\backslash$table$[[$Admission Date$],[($YYYY$-$MM$-$DD$)]],$Facility Name and Master Number,Referring Physician Name & Number$],[,,,,]]$

$\backslash$table$[[,,$ERVICE INFC,,$],[$Date $($YYYY$-$MM$-$DD$),$Code,# Services,Fee,Diagnosis$],[,,,,],[,,,,],[,,,,],[,,,,],[,,,,],[,,,,],[,,,,],[,,,,]]$