Chaparral Medical Group. Batch-ID: E BONITA AVE-912-OV

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1 Facility Name:790 E BONITA AVE Physician Name:RajeevKWalia Batch-ID: E BONITA AVE-912-OV Encounter Count:10 Printed Date:

2 PAT: HOOKER A,JO ANN 256 BROWNING AVE POMONA,CA /18/1952 PRI: (Y)PMED HEALTH NET COPAY,0.00: $0.00 SSN: APPT TIME: 8:45 AM VOUCHER: DETAILED EXAM F Current tobacco non-user (CAD, CAP, COPD, PV) (DM) (IBD) 1 G8752 Most recent systolic blood pressure < 140 mm Hg 1 G8754 Most recent diastolic blood pressure < 90 mm Hg 1 M Pain in left wrist N18.2 Chronic kidney disease, stage 2 (mild) I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease E11.22 Type 2 diabetes mellitus with diabetic chronic kidney disease E03.9 Hypothyroidism, unspecified R80.9 Proteinuria, unspecified K21.9 Gastro-esophageal reflux disease without esophagitis F33.9 Major depressive disorder, recurrent, unspecified Z80.0 Family history of malignant neoplasm of digestive organs Page 2

3 PAT: VILLALPANDO,CECILIA 953 N KANAS AVE COLTON,CA /03/1975 PRI: (Y)IEHP DIRECT COPAY,0.00: $0.00 SSN: APPT TIME: 8:30 AM VOUCHER: DETAILED EXAM F Current tobacco non-user (CAD, CAP, COPD, PV) (DM) (IBD) 1 E11.65 Type 2 diabetes mellitus with hyperglycemia I10 Essential (primary) hypertension E78.5 Hyperlipidemia, unspecified F41.9 Anxiety disorder, unspecified N95.1 Menopausal and female climacteric states Z83.49 Family history of other endocrine, nutritional and metabolic diseases E55.9 Vitamin D deficiency, unspecified E66.01 Morbid (severe) obesity due to excess calories Page 3

4 PAT: JERMOLOWICZ A,MARK 3514 HADLEY DRIVE MIRA LOMA,CA /10/1962 PRI: (Y)PMED PACIFICARE COPAY,0.00: $20.00 SSN: APPT TIME: 9:45 AM VOUCHER: EXPANDED EXAM ADMIN 1 It Flu, quad, SV age > 3 yrs IM 1 D49.2 Neoplasm of unspecified behavior of bone, soft tissue, and skin Z23 Encounter for immunization L98.9 Disorder of the skin and subcutaneous tissue, unspecified L Cellulitis of unspecified part of limb Page 4

5 Voucher Account Oct-2015 PMED PACIFICARE 6 JERMOLOWICZ, MARK A3514 HADLEY DRIVEMIRA LOMA, CA Rajeev K Walia 912 Copay($) : Method : Credit Rec'd on acct($) : 0.00 Refund Copay($) : 0.00 Voucher : vs3899 Total Amount($) : Payment received JERMOLOWICZ, Payment Collected ADIANE from: MARK A By: Bank Name: Voucher Date: 01-Jan-0001 Copay Remarks: Page 5

6 PAT: VALENZUELA C,BRUNO 831 CULMORE ST CLAREMONT,CA /06/1928 PRI: (Y)PMED INTERVALLEY SR COPAY,0.00: $0.00 SSN: APPT TIME: 10:00 AM VOUCHER: EXPANDED EXAM 1 J06.9 Acute upper respiratory infection, unspecified I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease N18.3 Chronic kidney disease, stage 3 (moderate) M12.9 Arthropathy, unspecified Page 6

7 PAT: WOODS R,CLIVE 904 EAST YALE ONTARIO,CA /07/1964 PRI: (Y)PMED CIGNA HEALTH CARE COPAY,0.00: $20.00 SSN: APPT TIME: 10:45 AM VOUCHER: COMPLEX EXAM 1 F41.9 Anxiety disorder, unspecified F32.9 Major depressive disorder, single episode, unspecified R07.9 Chest pain, unspecified E11.9 Type 2 diabetes mellitus without complications E78.5 Hyperlipidemia, unspecified K21.9 Gastro-esophageal reflux disease without esophagitis Z02.79 Encounter for issue of other medical certificate E55.9 Vitamin D deficiency, unspecified R53.83 Other fatigue Page 7

8 Voucher Account Oct-2015 PMED CIGNA HEALTH CARE 3 WOODS, CLIVE R904 EAST YALEONTARIO, CA Rajeev K Walia 912 Copay($) : Method : Credit Rec'd on acct($) : 0.00 Refund Copay($) : 0.00 Voucher : vs0036 Total Amount($) : Payment received WOODS, CLIVE Payment Collected ADIANE from: By: Bank Name: Voucher Date: 01-Jan-0001 Copay Remarks: Page 8

9 PAT: BROWN C,JOHN 1678 TULANE RD CLAREMONT,CA /27/1926 PRI: (Y)PMED INTERVALLEY SR COPAY,0.00: $0.00 SSN: APPT TIME: 2:15 PM VOUCHER: EXPANDED EXAM ADMIN 1 It Flu, quad, SV age > 3 yrs IM 1 I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease N18.3 Chronic kidney disease, stage 3 (moderate) R73.01 Impaired fasting glucose N40.0 Enlarged prostate without lower urinary tract symptoms M51.36 Other intervertebral disc degeneration, lumbar region E78.5 Hyperlipidemia, unspecified Z23 Encounter for immunization M51.16 Intervertebral disc disorders with radiculopathy, lumbar region Page 9

10 PAT: PEREZ A,MARCO 1244 BONNIE BRAE POMONA,CA /13/1952 PRI: (Y)BLUE SHIELD OF CALIFORNIA COPAY,0.00: $0.00 SSN: APPT TIME: 2:45 PM VOUCHER: DETAILED EXAM 1 E11.21 Type 2 diabetes mellitus with diabetic nephropathy E78.5 Hyperlipidemia, unspecified R80.9 Proteinuria, unspecified I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease N18.2 Chronic kidney disease, stage 2 (mild) Page 10

11 PAT: ROLEWICZ A,SUSAN KADOTA AVE POMONA,CA /14/1959 PRI: (Y)MEDICARE PART B CLAIMS LA COPAY,0.00: $0.00 LA CARE HEALTH PLAN SSN: APPT TIME: 3:30 PM VOUCHER: DETAILED EXAM 1 N13.6 Pyonephrosis L98.9 Disorder of the skin and subcutaneous tissue, unspecified R73.01 Impaired fasting glucose I11.0 Hypertensive heart disease with heart failure I50.9 Heart failure, unspecified I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris J44.9 Chronic obstructive pulmonary disease, unspecified E55.9 Vitamin D deficiency, unspecified Page 11

12 PAT: CONNARD R,ALGENE 2204 S GLENROY ST POMONA,CA /25/1932 PRI: (Y)PMED INTERVALLEY SR COPAY,0.00: $0.00 HEALTHNET SSN: APPT TIME: 3:45 PM VOUCHER: EXPANDED EXAM ADMIN 1 It Flu, quad, SV age > 3 yrs IM 1 E87.5 Hyperkalemia E11.21 Type 2 diabetes mellitus with diabetic nephropathy I12.9 Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris K21.9 Gastro-esophageal reflux disease without esophagitis Z23 Encounter for immunization R80.9 Proteinuria, unspecified Page 12

13 PAT: MARTINEZ E,PAUL 680 S. HAMILTON POMONA,CA /13/1993 PRI: (Y)UNITED HEALTHCARE COPAY,0.00: $20.00 SSN: APPT TIME: 3:00 PM VOUCHER: COMPREHENSIVE EXAM 1 M Pain in left knee R Other symptoms and signs involving the musculoskeletal system R25.3 Fasciculation M54.2 Cervicalgia E66.3 Overweight Z68.27 Body mass index (BMI) , adult Z83.3 Family history of diabetes mellitus M Pain in left toe(s) Page 13

14 Voucher Account Oct-2015 UNITED HEALTHCARE 189 MARTINEZ, PAUL E680 S. HAMILTONPOMONA, CA Rajeev K Walia 912 Copay($) : Method : Credit Rec'd on acct($) : 0.00 Refund Copay($) : 0.00 Voucher : vs1527 Total Amount($) : Payment received MARTINEZ, PAUL E Payment Collected ADIANE from: By: Bank Name: Voucher Date: 01-Jan-0001 Copay Remarks: Page 14

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