ATTACHMENT
Patient Name __John R. Jones____________
HIC# __123-45-6789D___________________
D.O.S. __8/3/98_________________________
Specific Spinal Region
| CPT Code |
ICD-9 Code Region |
ICD-9 Code - DX |
| _____________ |
________________________ |
________________________ |
| _____________ |
________________________ |
________________________ |
| _____________ |
________________________ |
________________________ |
PERMANENT SUBLUXATION
Date of X-ray __3/19/96_C________
Region: __Lumbopelvic 739.3______
Permanent Condition ICD-9 Code __722.52____________________
Provider ________________________________
Provider # ______________________________