Pt Name______Frost / King / Krisel / Lewis Date / Time______Est care / Annual / Continuity / Urgent

Room Number ______Encounter Form Non ILM Medicare

Provider Fees Lab Work Processed at IFMA Establish Care / Annual Exam $0 See Below Strep Test $5 cpt 87880 Continuity / Urgent Visit $20 99203 / 99213 Urinalysis $5 cpt 81002 Complex Continuity Visit $180 cpt 99214 Stool Hemoccult $5 Nutrition Consult $20 97802 / 97803 Wet Prep/KOH $15 Comprehensive Physical Exam $708 Pregnancy Test $25 cpt 81025 Holistic Consult Flu Test $35 cpt 87804 Specialty Consult $90 School, Sports, Work Physical $20 cpt 99201 Lab Work Processed Offsite Annual Screening Panel $29 Annual Physical Exam CBC-Blood Count $5 cpt 85025 New Established Age CMP-Complete Chemistry $5 cpt 80053 99381 99391 under 1 Lipid Panel-Cholesterol Panel $5 cpt 80061 99382 99392 age 1-4 Vitamin D $30 cpt 82306 99383 99393 age 5-11 CRP $5 cpt 86141 99384 99394 age 12-17 CRP High Sensitivity $15 cpt 86141 99385 99395 age 18-39 Ferritin $15 cpt 82728 99386 99396 age 40-64 FOBT $25 cpt 82274 Glucose - Fasting $5 cpt 82947 Procedures/Treatments & Supplies H. Pylori Stool $40 cpt 86677 Biopsy <5mm $50 cpt 11400 HgbA1C $5 cpt 83036 Biopsy >6mm $50 cpt 11401 Homocysteine $31 cpt 83090 Biopsy Pathology** $60 Hormone Panel Cryosurgery-max 4 $46 cpt 17003 Saliva/Urine/Blood Dressing $10 cpt A6216 Complete/Female/Male/Adrenal Ear Irrigation $15 cpt 69210 Iron and TIBC $15 83540; 83550 EKG $5 cpt 93000 Micro-albumin Urine Test $47 cpt 82043 Fluorescein eye exam $3 N/A Mono Test $20 cpt 86308 Laceration Repair <2.5cm $95 cpt 12001 PSA-Prostate Screen $5 cpt 84153 Laceration Repair >2.5cm $95 cpt 12002 SED Rate ESR $25 cpt 85652 Minor Procedure $46 Stool Studies-o&p, leukocytes, culture $77 Nebulizer Treatment $30 cpt 94640 Testosterone, Free & Total $55 84402; 84403 Pelvic Exam $0 Throat Culture $20 cpt 87070 Pap Exam + HPV $72 87624;88175 Thyroid Panel $70 Pap Pathology** quantity # $25 cpt 88142 Thyroglobulin AB $18 cpt 86800 Urine Strainer $10 TSH $15 cpt 84443 T3F $13 cpt 84481 Other: T4F $13 cpt 84439 Reverse T3 $30 cpt 84482 Orthopedic Supplies TPO Antibody $25 cpt 86376 Air Cast $40 cpt L4350 Thyroid F/U Panel (TSH, T3F/T4F, rT3) $45 Arm Sling $30 cpt 156450 Urine Culture $20 cpt 87086 Crutches $30 cpt E0112 Urine Iodine $55 cpt 83789 Finger Splint $10 cpt 13029 Vitamin B12 $15 cpt 82607 Knee Sleeve $29 cpt L4380 Wound Culture $36 Post Op Shoe $40 cpt L3260 Shoulder Immobilizer $30 cpt L3670 Other: Tennis Elbow Universal $30 cpt L3700 Wrist Splint $40 cpt L3908 Other:

Injections / Medications Patient Handouts Ancef $40 cpt J0690 5 Wishes $3.21 B12 $15 Allergy Handout Flu Vaccine $20 Anti-Inflamatory Diet Joint Injection $70 ASQ Questionaire Rocephin $25 cpt J0696 Elimination Diet Solu-medrol $30 cpt J2920 Good RX card Tb Skin Test $15 Lara's card Tetanus (Td) $44 cpt 90714 Mindfulness Based Stress Reduction Tetanus (Tdap) $56 cpt 90714 Wound Care Instructions Toradol $40 cpt J1885 Injection Fee - NILM $15 cpt 90722 Other: ** Non IFMA physician fee ICD 10 Codes Continuity of Care

1. ______F/U______

2. ______Med Records______

3. ______Labs Fasting 2-3 days prior to f/u

4. ______Nutritional Coaching Health Coaching

5. ______Other______

Greater than 50% of visit spent on counseling and coordination of care. Total Referral to: ______time spent with patient ______minutes. For: ______

IDC 10: ______*Insurance cards are needed on file for specialty referrals

By my signature I authorize treatment and any diagnostic procedure deemed necessary by the attending provider and agree that payment will be made in FULL at the end of my office visit for services rendered.

We provide holistic health consults, which are not covered by Medicare or Medicaid. Other insurers may reimburse the patient directly for some portion of charges according to their policy benefits.

Patient's signature:______Date______

By my signature below, I certify that I am a licensed healthcare provider in the state of NC and have provided these medical services.

Provider's signature:

Chad Krisel, MD NPI#1841235397: ______Date______

Brian Lewis, MD MPH NPI#1942255013______Date______

Elizabeth Frost, PA-C NPI#1689055493______Date______

Melissa King, PA-C NPI#1952712952: ______Date______

Katherine Wilson, MSHN: ______Date______

Integrative Family Medicine of Asheville p: 828.575.9600 372 Depot Street Suite #10 f: 828.575.2298 Asheville, NC 28801 Tax ID: #45-3200283