X
  
  
  
                                          Subscriber, Original
  Payer                                   234 Main St
  123 Main St                             American Fork, UT  84003-0002
  Ste 100
  American Fork, UT  84003-0001           01/01/1970     X      123456789
  
                           X              12345         Employer Name
   
 Subscriber, Other
                                           X                           X
 01/01/1970     X      234567890
                                          Patient, Bob
 12345         X                          456 Main St.
 Other Payer                              American Fork, UT  84003-0004
 345 Main St
 American Fork, UT  84003-0003                           X     345678901
 
 
 
  10/24/2012  10  JP 24        O     D2391 Resin-1 surface posterior       76.00
  
  
  
  
  
  
  
  
  
                 X                                                 X
                 X                                                 X     76.00
      Remarks Remarks Remarks



                                           X                        1    1    1

  SIGNATURE ON FILE          10/30/2012    X                     10/30/2012
  
                                           24       X            10/30/2012
  
  SIGNATURE ON FILE          10/30/2012    X
  
  
  
 Billing Provider                          SIGNATURE ON FILE          10/30/2012
 567 Main St                               
                                               78901234             890123456
 American Fork, UT  84003-0004                                      122300000X
                                          678 Main St
 4567891      567890123    67890123       American Fork, UT  84003-0005
       801 642 0300                            801 642 0300