Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Alers, Cindy   DOB:07/08/1982 Tel:917-501-4438 SSN:  Sex: F

   Address:6111 64th Street, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Alers,Cindy  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. MagnaCare, PO BOX 1001, GARDEN CITY, NY 11530
    Copay:   Subscriber No:6826289422   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Walter, Deanna R   DOB:11/25/1987 Tel:313-350-1060 SSN:  Sex: F

   Address:71-13 60th Lane Apt 402, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Walter,Deanna R 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Cigna, PO Box 188055, Chattanooga, TN 37422
    Copay:   Subscriber No:106219209   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. B34.9 Viral syndrome   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822B34.9 20 1 1.00 $172.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 09:03:27 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Mastrolembo, Robert G   DOB:03/04/1993 Tel:917-940-6027 SSN:  Sex: M

   Address:7724 64TH LN, RIDGEWOOD, NY 11385-6154
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Mastrolembo,Robert G 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. OXFORD, PO BOX 29130, HOT SPRINGS, AR 71903-9041
    Copay:   Subscriber No:65942337500   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 09:03:01 EST : Eligible : InEligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Lawrence, Matthew   DOB:06/12/1990 Tel:925-209-7530 SSN:  Sex: M

   Address:6044 PUTNAM AVE, RIDGEWOOD, NY 11385-4558
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Lawrence,Matthew  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Healthfirst Inc New York, 25 Broadway 9th Floor, New York, NY 10004
    Copay:   Subscriber No:420000047767500   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

notesEligibility :2021-11-09 @ 11:33:50 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 11:33:49

EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 09:13:39 EST : Cannot Process; notesEligibility
Notes :2021-11-09 @ 09:13:39 EST : Cannot Process; notesEligibility :2021-11-09 @ 09:13:39 EST : Cannot
Process; notesEligibility :2021-11-09 @ 09:13:38 EST : Cannot Process; notesEligibility :2021-11-09 @
09:13:11 EST : Cannot Process; notesEligibility :2021-11-09 @ 09:13:11 EST : Cannot Process;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Gagliardotto, Gina   DOB:04/12/1992 Tel:646-623-8290 SSN:  Sex: F

   Address:7114 CENTRAL AVE, RIDGEWOOD, NY, US 11385-7319
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Gagliardotto,Gina  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. UNITED HEALTH CARE, PO BOX 740800, ATLANTA, GA 30374-0484
    Copay:   Subscriber No:951945741   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. B34.9 Viral syndrome   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822B34.9 20 1 1.00 $172.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 09:10:36 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Barberi, Maryann   DOB:03/23/1966 Tel:631-626-8407 SSN:  Sex: F

   Address:6344 60TH PL, RIDGEWOOD, NY 11385-2041
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Barberi,Maryann  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Anthem, 165 BROADWAY, NEW YORK, NY 10006-1404
    Copay:   Subscriber No:LBN000408014   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. M25.551 Right hip pain (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 M25.551 20 1 1.00 $172.00
  73120 X-RAY EXAM OF HAND 20 1 1.00 $69.00
  73552 X-RAY EXAM OF FEMUR 2></div> 20 1 1.00 $80.00

Co-Pay Paid 50.00   Cash

Notes notesEligibility :2021-11-09 @ 09:17:41 EST : Eligible : Eligible;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Raiford, Justin D   DOB:02/10/1983 Tel:512-626-7940 SSN:  Sex: M

   Address:1924 Hemrod Street, Ridgewood, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Raiford,Justin D 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:ntb919743955   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  36415 VENIPUNCT, ROUTINE* 20 1 1.00 $30.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 09:12:38 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

MOEHRKE, AUGUST HENRY   DOB:10/04/1995 Tel:917-767-6713 SSN:  Sex: M

   Address:6044 PUTNAM AVE, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:MOEHRKE,AUGUST HENRY  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:DOMAN8585981   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 09:36:59 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Sanchez, Karina   DOB:11/01/1984 Tel:347-836-0309 SSN:  Sex: F

   Address:6022 61ST ST, MASPETH, NY 11378-3520
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Sanchez,Karina  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. BCBS Health Plus, PO BOX 61010, VIRGINIA BEACH, VA 23466-1010
    Copay:   Subscriber No:jlj006474684   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 09:29:23 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Ortiz, Judy   DOB:06/04/1958 Tel:646-457-7715 SSN:  Sex: F

   Address:7931 67TH RD, APT 3, MIDDLE VILLAGE, NY, US 11379-2975
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Ortiz,Judy  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. HIP, PO BOX 2845, NEW YORK, NY 10116
    Copay:50.00   Subscriber No:k1013411101   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  36415 VENIPUNCT, ROUTINE* 20 1 1.00 $30.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

notesEligibility :2021-11-09 @ 09:37:05 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 09:36:50

Notes
EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 09:36:50 EST : Eligible : Eligible;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Wrigley, Gabriel   DOB:05/31/2011 Tel:646-269-3767 SSN:  Sex: F

   Address:6433 68TH AVE, RIDGEWOOD, NY, US 11385-4643
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Wrigley,William  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. GHI HMO Select, PO Box 4141, Kingston, NY 12402
    Copay:50.00   Subscriber No:K9067001404   Group No:

   
Insured's Name:Wrigley,William    
Insured's relation to patient:Parent
    Insured's Address:2, 64-33 68th Street, RIDGEWOOD, NY 11385

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. J02.9 Viral pharyngitis   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822J02.9 20 1 1.00 $172.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00
  87880 STREP A ASSAY W/OPTIC Z20.822 20 1 1.00 $25.00

notesEligibility :2021-11-09 @ 09:29:46 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 09:29:46

EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 09:29:46 EST : Eligible : Eligible; notesEligibility
Notes
:2021-11-09 @ 09:29:41 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 09:29:41 EST : Eligible :
Eligible; notesEligibility :2021-11-09 @ 09:29:41 EST : Eligible : Eligible;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Pizzoli, Lorenzo   DOB:02/08/1982 Tel:516-474-7585 SSN:  Sex: M

   Address:1674 Norman Street, Ridgewood, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Pizzoli,Lorenzo  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. OXFORD, PO BOX 29130, HOT SPRINGS, AR 71903-9041
    Copay:   Subscriber No:40502460801   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes notesEligibility :2021-11-09 @ 09:26:51 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Villamizar, Obdulia   DOB:09/04/1948 Tel:347-855-1460 SSN:  Sex: F

   Address:7148 68 Th St, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Villamizar,Obdulia  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:jwx128m88193   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. L02.91 Abscess (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 L02.91 20 1 1.00 $172.00

Notes notesEligibility :2021-11-09 @ 09:38:53 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Marcheva, Stoyanka   DOB:05/23/1967 Tel:347-403-0041 SSN:  Sex: F

   Address:6001 69TH AVE, APT 3, RIDGEWOOD, NY 11385-5199
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Marcheva,Stoyanka  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:ETRBJ1023666   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 09:59:40 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

BUDLLA, FERDINAND   DOB:07/30/1979 Tel:929-624-8801 SSN:  Sex: M

   Address:16151 JEWEL AVE, FRESH MEADOWS, NY 11365
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:BUDLLA,FERDINAND  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. MagnaCare, PO BOX 1001, GARDEN CITY, NY 11530
    Copay:   Subscriber No:4536753771   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Burke, John   DOB:03/05/2008 Tel:347-969-8656 SSN:  Sex: M

   Address:6108 82nd St, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Burke,John  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:jlj731813281   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. B34.9 Viral syndrome   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822B34.9 20 1 1.00 $172.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 10:02:34 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

BURKE, MAKAYLA   DOB:05/20/2004 Tel:917-225-8126 SSN:  Sex: F

   Address:6108 82nd St, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:BURKE,MAKAYLA  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:JLJ31813282   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. J02.9 Acute pharyngitis   
3. B34.9 Viral syndrome   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822J02.9 B34.9 20 1 1.00 $172.00
  87880 STREP A ASSAY W/OPTIC 20 1 1.00 $25.00
  87880 STREP A ASSAY W/OPTIC 20 1 1.00 $25.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00
  87804 INFLUENZA ASSAY W/OPTIC 20 1 1.00 $50.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Torchala, Damian   DOB:06/30/1990 Tel:929-395-2869 SSN:  Sex: M

   Address:8717 102ND ST, APT A5, RICHMOND HILL, NY 11418-2023
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Torchala,Damian  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

COLON, LAUREN   DOB:01/06/1990 Tel:929-474-4145 SSN:  Sex: F

   Address:82 SOUTH 3RD ST, BROOKLYN, NY 11211
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:COLON,LAUREN  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Aetna, PO BOX 14079, LEXINGTON, KY 40512
    Copay:   Subscriber No:W259524397   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 10:29:40 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

GJEKA, SUADA   DOB:10/08/1977 Tel:646-894-4502 SSN:  Sex: F

   Address:1529 GREENE AVE, Brooklyn, NY 11237
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:GJEKA,SUADA  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:ETRBJ0648576   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

notesEligibility :2021-11-09 @ 10:27:34 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 10:27:34

Notes
EST : Eligible : Eligible;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Brzostowski, Antoni   DOB:01/17/1963 Tel:347-449-1273 SSN:  Sex: M

   Address:6333 FOREST AVE, APT 2R, RIDGEWOOD, NY, US 11385-2011
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia

Responsible Party Name:Brzostowski,Antoni  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. MagnaCare, PO BOX 1001, GARDEN CITY, NY 11530
    Copay:   Subscriber No:477832   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. S93.402A Sprain of left ankle, unspecified ligament, initial encounter (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 S93.402A 20 1 1.00 $172.00
  73610 X-RAY EXAM OF ANKLE 20 1 1.00 $76.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Brzostowski, Lukasz   DOB:02/07/1986 Tel:917-627-3186 SSN:  Sex: M

   Address:2R, 6333 Forest Ave, RIDGEWOOD, NY, US 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia

Responsible Party Name:Brzostowski,Lukasz  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:IUE054W02598   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. M79.675 Pain of left great toe (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 M79.675 20 1 1.00 $172.00

Notes notesEligibility :2021-11-09 @ 10:33:31 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Stephan, Dennis   DOB:06/05/1976 Tel:516-695-9664 SSN:  Sex: M

   Address:6082 71st St, MASPETH, NY 11378
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Stephan,Dennis  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:dpe023w08042   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 10:34:59 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Rodriguez, Valerie   DOB:09/12/1993 Tel:347-385-8657 SSN:  Sex: F

   Address:6958 78TH ST, MIDDLE VILLAGE, NY 11379-2844
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Rodriguez,Valerie  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. MetroPlus Health Plan, PO Box 1966, New York, NY 10116
    Copay:   Subscriber No:vt21910d   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes notesEligibility :2021-11-09 @ 10:33:57 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

PETELA, JADWIGA   DOB:10/15/1960 Tel:718-308-5815 SSN:  Sex: F

   Address:5346 72ND ST, 1, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:PETELA,JADWIGA  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Emblem Health, PO BOX 3000, NY, NY 10116-3000
    Copay:   Subscriber No:K6013005101   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

notesEligibility :2021-11-09 @ 10:35:50 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 10:35:49

Notes
EST : Eligible : Eligible;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Burnar, Lucica   DOB:01/20/1956 Tel:646-510-0194 SSN:  Sex: F

   Address:5729 Catalpa Ave, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Burnar,Lucica  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. MetroPlus Health Plan, PO Box 1966, New York, NY 10116
    Copay:   Subscriber No:pm07320u   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. M54.2 Neck pain (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 M54.2 20 1 1.00 $172.00
  72040 X-RAY EXAM OF NECK SPINE 20 1 1.00 $80.00

Notes notesEligibility :2021-11-09 @ 11:33:22 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

FELICIANO, ABDUL   DOB:10/23/1986 Tel:718-415-8454 SSN:  Sex: M

   Address:2175 BERGEN ST, APT D, NY 11233
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:FELICIANO,ABDUL  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. UNITED HEALTH CARE, PO BOX 740800, ATLANTA, GA 30374-0484
    Copay:   Subscriber No:119893806   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 10:49:13 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Walton, Orien   DOB:02/06/1992 Tel:434-709-9800 SSN:224-65-6710  Sex: M

   Address:2175 BERGEN ST, APT 3D, BROOKLYN, NY, US 11233
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Walton,Orien  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. UNITED HEALTH CARE, PO BOX 740800, ATLANTA, GA 30374-0484
    Copay:   Subscriber No:119985294   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 10:49:02 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Bozo, VIVIEN   DOB:02/08/1993 Tel:929-430-9250 SSN:  Sex: F

   Address:6136 WOODBINE ST, APT 2B, RIDGEWOOD, NY 11385-4018
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Bozo,VIVIEN  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Cigna, PO Box 188055, Chattanooga, TN 37422
    Copay:   Subscriber No:105637415   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

GALLEGO, ANDRE   DOB:12/22/2020 Tel:347-320-5681 SSN:  Sex: M

   Address:6870 76TH ST, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:GALLEGO,ANDRE  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Guzman, Tiffany J   DOB:09/10/1988 Tel:347-331-8007 SSN:  Sex: F

   Address:819 Fdr Dr, NEW YORK, NY 10009
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Guzman,Tiffany J 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Emblem Health, PO BOX 3000, NY, NY 10116-3000
    Copay:   Subscriber No:k9037004201   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   
3. Z23 Encounter for immunization   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828Z23 20 1 1.00 $51.00
  91300 PFIZER VACCINE Z20.822 20 80 1.00
  0001A ADM SARSCOV2 30MCG/0.3ML 1ST Z20.822 20 1.00
   COVID- 19 PFIZER 1.00

Notes notesEligibility :2021-11-09 @ 11:13:36 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

BAKER, WILLIAM F   DOB:04/10/1963 Tel:917-363-9891 SSN:  Sex: M

   Address:6040 77TH PL, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:BAKER,WILLIAM F 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Emblem Health, PO BOX 3000, NY, NY 10116-3000
    Copay:   Subscriber No:K9030790101   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

notesEligibility :2021-11-09 @ 11:13:46 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 11:13:45

EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 11:13:45 EST : Eligible : Eligible; notesEligibility
Notes :2021-11-09 @ 11:12:05 EST : Cannot Process; notesEligibility :2021-11-09 @ 11:12:02 EST : Eligible :
Eligible; notesEligibility :2021-11-09 @ 11:12:01 EST : Eligible : Eligible; notesEligibility :2021-11-09 @
11:11:54 EST : Cannot Process;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Romero, Sophia   DOB:07/04/1990 Tel:718-808-2530 SSN:  Sex: F

   Address:59-62 58TH AVE, MASPETH, NY, US 11378
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Romero,Sophia  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Sausa, Richard A   DOB:11/17/2005 Tel:718-894-8502 SSN:  Sex: M

   Address:6035 59 Dr, MASPETH, NY, US 11378
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Sausa,Richard  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Emblem Health, PO BOX 3000, NY, NY 10116-3000
    Copay:   Subscriber No:k9029358304   Group No:

   
Insured's Name:Sausa,Richard    
Insured's relation to patient:Other
    Insured's Address:60-35-59YH DRIVE, MASPETH, NY 11378

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. B34.9 Viral syndrome   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99203 Office Visit, New Pt., Level 3 Z20.822 20 1 1.00 $258.00
  87880 STREP A ASSAY W/OPTIC 20 1 1.00 $25.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

MCINTIRE, BRADEN   DOB:11/20/2010 Tel:917-748-9930 SSN:  Sex: M

   Address:5760 81ST ST, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:MCINTIRE,BRADEN  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Emblem Health, PO BOX 3000, NY, NY 10116-3000
    Copay:   Subscriber No:K9026063905   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. J02.9 Acute pharyngitis   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822J02.9 20 1 1.00 $172.00
  87880 STREP A ASSAY W/OPTIC 20 1 1.00 $25.00
  87880 STREP A ASSAY W/OPTIC 20 1 1.00 $25.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 11:36:32 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

BORST, RICHARD T   DOB:10/08/1953 Tel:917-502-5050 SSN:  Sex: M

   Address:6112 69TH ST, APT 1H, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:BORST,RICHARD T 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Medicare, PO Box 4751, Syracuse, NY 13221
    Copay:   Subscriber No:3U91VN6XH94   Group No:

   
Insured's relation to patient:Self - patient is the insured
2. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:R50215517   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. B34.9 Viral syndrome   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822B34.9 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00
  87804 INFLUENZA ASSAY W/OPTIC 20 1 1.00 $50.00

notesEligibility :2021-11-09 @ 11:24:01 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 11:24:01

Notes EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 11:24:01 EST : Eligible : Eligible; notesEligibility
:2021-11-09 @ 11:23:56 EST : Eligible : InEligible : Eligible;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

RADNEVA, ILIANA   DOB:06/16/1986 Tel:641-275-0270 SSN:  Sex: F

   Address:6102 PALMETTO ST, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:RADNEVA,ILIANA  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Aetna, PO BOX 14079, LEXINGTON, KY 40512
    Copay:   Subscriber No:W265505413   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

notesEligibility :2021-11-09 @ 11:38:06 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 11:38:04

Notes
EST : Eligible : Eligible;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

PRUSINOWSKI, STEFAN   DOB:05/15/1946 Tel:347-798-4842 SSN:  Sex: M

   Address:59-75 57TH DR, MASPETH, NY 11378
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:PRUSINOWSKI,STEFAN  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:Y7N093W06730   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 12:09:16 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Vesneske, Maya   DOB:08/14/1998 Tel:617-631-4682 SSN:  Sex: F

   Address:1070 Bedford, BROOKLYN, NY 11216
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Vesneske,Maya  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Cigna, PO Box 188055, Chattanooga, TN 37422
    Copay:   Subscriber No:99111816903   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 12:08:57 EST : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

MUNTEAN, SORIN   DOB:05/17/1969 Tel:917-620-1211 SSN:  Sex: M

   Address:5954 WOODBINE ST, APT 3A, RIDGEWOOD, NY 11385-3202
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:MUNTEAN,SORIN  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:GRW826486428   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. U07.1 COVID-19   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822U07.1 20 1 1.00 $172.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 12:08:48 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Ega, Emily   DOB:11/22/1996 Tel:917-971-3502 SSN:  Sex: F

   Address:6930 62ND ST, APT 4E, RIDGEWOOD, NY 11385-5265
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Ega,Emily  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Healthfirst Inc New York, 25 Broadway 9th Floor, New York, NY 10004
    Copay:   Subscriber No:tv52010z   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. B34.9 Viral syndrome   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822B34.9 20 1 1.00 $172.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

notesEligibility :2021-11-09 @ 12:13:39 EST : Cannot Process; notesEligibility :2021-11-09 @ 12:13:29

EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 12:13:28 EST : Eligible : Eligible; notesEligibility
Notes
:2021-11-09 @ 12:13:25 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 12:13:25 EST : Eligible :
Eligible; notesEligibility :2021-11-09 @ 12:13:23 EST : Cannot Process;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

KAUR, EKAM   DOB:06/16/2016 Tel:718-326-9085 SSN:  Sex: F

   Address:5813 60TH LN, MASPETH, NY 11378
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:KAUR,EKAM  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:DJL000070848   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822 20 1 1.00 $172.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 12:04:53 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Szczesny, Marcel   DOB:10/30/2010 Tel:347-488-9333 SSN:  Sex: M

   Address:5610 NURGE AVE, MASPETH, NY, US 11378-3339
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Chrzanowska,Ewa  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Fidelis Care New York, PO Box 8052, Amherst, NY 14226
    Copay:0.00   Subscriber No:74398299400   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 12:13:05 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

GUZMAN, EDGAR I   DOB:07/08/1992 Tel:347-423-9270 SSN:  Sex: M

   Address:6298 WOODHAVEN BLVD, REGO PARK, NY 11374-3738
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:GUZMAN,EDGAR I 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. GHI New York, PO BOX 3000, NEW YORK, NY 10116-3000
    Copay:   Subscriber No:K90331197   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 12:35:59 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Padovani, Anthony   DOB:08/09/1965 Tel:646-744-4633 SSN:  Sex: M

   Address:20 OAK ST, FLORAL PARK, NY 11001-3120
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Padovani,Anthony  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:jlj720989643   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 12:36:11 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

COLLADO, ARLINDA   DOB:04/16/1971 Tel:646-744-4633 SSN:  Sex: F

   Address:20 OAK ST, FLORAL PARK, NY 11001-3120
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:COLLADO,ARLINDA  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:JLJ720990005   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 15:07:01 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

PADOVANI, SARAH   DOB:08/18/2002 Tel:646-744-4633 SSN:  Sex: F

   Address:20 OAK ST, FLORAL PARK, NY 11001
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:PADOVANI,SARAH  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:JLJ720989619   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 12:47:48 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

PADOVANI, MARY   DOB:03/04/2010 Tel:646-744-4633 SSN:  Sex: F

   Address:20 OAK ST, FLORAL PARK, NY 11001
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:PADOVANI,MARY  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:JLJ720989619   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Debono, Isabelle M   DOB:01/20/1989 Tel:347-846-3367 SSN:  Sex: F

   Address:6511 Claran Court, MASPETH, NY 11378
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Debono,Isabelle M 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

LEAL, DANIELA   DOB:09/10/1990 Tel:646-824-3558 SSN:  Sex: F

   Address:7119 69TH ST, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:LEAL,DANIELA  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. MetroPlus Health Plan, PO Box 1966, New York, NY 10116
    Copay:   Subscriber No:XD67449X   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 15:06:32 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Trejgis, Elzbieta   DOB:06/03/1979 Tel:917-767-8302 SSN:  Sex: F

   Address:5904 FRESH POND RD, MASPETH, NY 11378-3468
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Trejgis,Elzbieta  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

TRAN, WES   DOB:10/24/2020 Tel:617-230-6128 SSN:  Sex: M

   Address:5934 WOODBINE, 2, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:TRAN,WES  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Emblem Health, PO BOX 3000, NY, NY 10116-3000
    Copay:   Subscriber No:K9069180403   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

notesEligibility :2021-11-09 @ 15:05:58 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 15:05:57

Notes
EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 15:05:57 EST : Eligible : Eligible;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

RIVERA, VERONICA   DOB:02/06/1993 Tel:347-884-2231 SSN:  Sex: F

   Address:285 LINDEN ST, 1B, Brooklyn, NY 11237
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:RIVERA,VERONICA  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Fidelis Care New York, PO Box 8052, Amherst, NY 14226
    Copay:   Subscriber No:74300439300   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 12:55:01 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Figueroa, Virginia   DOB:01/09/1973 Tel:718-664-3146 SSN:  Sex: F

   Address:6118 68th Ave, Fl 1, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Figueroa,Virginia  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. HIP, PO BOX 2845, NEW YORK, NY 10116
    Copay:   Subscriber No:K1010435901   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 14:01:41 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

NEIRA, MIGUEL   DOB:12/23/1972 Tel:917-299-2602 SSN:  Sex: M

   Address:5763 58TH ST, MASPETH, NY 11378-2239
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:NEIRA,MIGUEL  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. UNITED HEALTH CARE, PO BOX 740800, ATLANTA, GA 30374-0484
    Copay:   Subscriber No:943621423   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 13:04:26 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Neira, Daniel X   DOB:08/06/2003 Tel:917-299-2602 SSN:  Sex: M

   Address:5763 58TH ST, MASPETH, NY 11378-2239
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Neira,Daniel X 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. UNITED HEALTH CARE, PO BOX 740800, ATLANTA, GA 30374-0484
    Copay:   Subscriber No:943621423   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 13:04:17 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

FIGUEROA, BETHANY   DOB:12/11/2004 Tel:718-664-3146 SSN:  Sex: F

   Address:6118 68th Ave, Fl 1, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:FIGUEROA,BETHANY  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. HIP, PO BOX 2845, NEW YORK, NY 10116
    Copay:   Subscriber No:K1010435904   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

notesEligibility :2021-11-09 @ 14:01:59 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 14:01:58

Notes
EST : Eligible : Eligible;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

MARKOVICH, AEDIN   DOB:04/08/2008 Tel:917-686-7299 SSN:  Sex: M

   Address:61-25 64TH ST, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:MARKOVICH,AEDIN  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Emblem Health, PO BOX 3000, NY, NY 10116-3000
    Copay:   Subscriber No:K9061506003   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes Closed fracture of shaft of left radius, unspecified fracture morphology, initial
1. S52.302A
encounter (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 S52.302A 20 1 1.00 $172.00
  73110 X-RAY EXAM OF WRIST 20 1 1.00 $85.00

Co-Pay Paid 50.00   Credit Card

Notes notesEligibility :2021-11-09 @ 13:02:13 EST : Eligible : Eligible;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

SHEHATA, OMAR A   DOB:08/08/2005 Tel:646-633-2694 SSN:  Sex: M

   Address:9031 WHITNEY AVE, ELMHURST, NY 11373-1670
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:SHEHATA,OMAR A 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Fidelis Care New York, PO Box 8052, Amherst, NY 14226
    Copay:   Subscriber No:744258389-00   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 14:01:23 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Aversa, Doreen   DOB:03/20/1971 Tel:718-496-3300 SSN:  Sex: F

   Address:8460 Goldington Ct, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Aversa,Doreen  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Aetna, PO BOX 14079, LEXINGTON, KY 40512
    Copay:   Subscriber No:w252823267   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 13:27:09 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

AVERSA, FRANK   DOB:09/09/1971 Tel:718-607-0968 SSN:  Sex: M

   Address:8460 GOLDINGTON CT, MIDDLE VILLAGE, NY 11379-2431
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:AVERSA,FRANK  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Aetna, PO BOX 14079, LEXINGTON, KY 40512
    Copay:   Subscriber No:W25282326702   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

notesEligibility :2021-11-09 @ 13:27:30 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 13:27:30

EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 13:27:29 EST : Eligible : Eligible; notesEligibility
Notes
:2021-11-09 @ 13:27:29 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 13:27:19 EST : Eligible :
Eligible;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Alvarez, Tito   DOB:11/25/1966 Tel:347-225-1375 SSN:  Sex: M

   Address:6223 64TH ST, MIDDLE VILLAGE, NY, US 11379-1068
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Alvarez,Tito  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Healthfirst Inc New York, 25 Broadway 9th Floor, New York, NY 10004
    Copay:   Subscriber No:vd38410v   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. B34.9 Viral syndrome   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822B34.9 20 1 1.00 $172.00
  36415 VENIPUNCT, ROUTINE* 20 1 1.00 $30.00
  87426 rapid covid testing 20 1 1.00 $100.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00
  87804 INFLUENZA ASSAY W/OPTIC 20 1 1.00 $50.00

Notes notesEligibility :2021-11-09 @ 13:21:39 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Barta, John   DOB:03/02/1966 Tel:718-381-9319 SSN:  Sex: M

   Address:6058 70TH AVE, RIDGEWOOD, NY, US 11385-5166
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Barta,John  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:40.00   Subscriber No:ioe978w05698   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 13:54:06 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Baez De Zapata, Juana   DOB:05/27/1985 Tel:347-691-5125 SSN:  Sex: F

   Address:1218 Decatur St, BROOKLYN, NY 11207
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Baez De Zapata,Juana  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Healthfirst Inc New York, 25 Broadway 9th Floor, New York, NY 10004
    Copay:   Subscriber No:420000080213500   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. T78.40XA Allergy, initial encounter (primary)  

2. R09.81 Nasal congestion   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 T78.40XAR09.81 20 1 1.00 $172.00

Notes notesEligibility :2021-11-09 @ 13:44:37 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

SANCHEZ, CLAUDIA   DOB:10/12/1981 Tel:347-803-5397 SSN:  Sex: F

   Address:5408 FLUSHING AVE, MASPETH, NY 11378
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:SANCHEZ,CLAUDIA  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. United Healthcare Community Plan, POB OX 31348, Salt Lake City, UT 84131
    Copay:   Subscriber No:114265074   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z23 Encounter for immunization   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z23 20 1 1.00 $51.00
  91300 PFIZER VACCINE Z20.822 20 80 1.00
  0001A ADM SARSCOV2 30MCG/0.3ML 1ST Z20.822 20 1.00
   COVID- 19 PFIZER 1.00

Notes notesEligibility :2021-11-09 @ 14:01:13 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

TORIBIO, JOSE   DOB:06/22/1972 Tel:347-803-5397 SSN:  Sex: M

   Address:1662 GEORGE ST, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:TORIBIO,JOSE  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. United Healthcare Community Plan, POB OX 31348, Salt Lake City, UT 84131
    Copay:   Subscriber No:119601263   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z23 Encounter for immunization   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  91300 PFIZER VACCINE Z20.822 20 80 1.00
  0001A ADM SARSCOV2 30MCG/0.3ML 1ST Z20.822 20 1.00
   COVID- 19 PFIZER 1.00

Notes notesEligibility :2021-11-09 @ 14:01:04 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

SHEHATA, AMR S   DOB:01/12/1971 Tel:646-633-2694 SSN:  Sex: M

   Address:9031 WHITNEY AVE, ELMHURST, NY 11373-1670
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:SHEHATA,AMR S 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Fidelis Care New York, PO Box 8052, Amherst, NY 14226
    Copay:   Subscriber No:744336842-00   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 14:00:54 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

ORMENO ROSERO, ELIO U   DOB:06/22/1949 Tel:347-938-9739 SSN:  Sex: M

   Address:6156 ELIOT AV, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:ORMENO ROSERO,ELIO U 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Ortiz, Justin   DOB:08/25/1996 Tel:347-827-9193 SSN:  Sex: M

   Address:5934 60TH ST, MASPETH, NY, US 11378-3235
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Ortiz,Justin  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Emblem Health, PO BOX 3000, NY, NY 10116-3000
    Copay:   Subscriber No:K6021020801   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. J06.9 Viral upper respiratory infection (primary)  

2. Z20.822 Contact with and (suspected) exposure to covid-19   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 J06.9 20 1 1.00 $172.00

notesEligibility :2021-11-09 @ 14:13:53 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 14:13:52

Notes
EST : Eligible : Eligible;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

VILLASISPAZ, GEORGE GARY   DOB:04/11/2002 Tel:347-985-3342 SSN:  Sex: M

   Address:7128 66TH PL, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:VILLASISPAZ,GEORGE GARY  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. TRICARE EAST REGIONAL CLAIMS, PO BOX 7981, MADISON, WI 53707-7900
    Copay:   Subscriber No:01969665500   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

RAGANO, GIOVANNA   DOB:12/01/1991 Tel:347-728-7708 SSN:  Sex: F

   Address:16432 92ND ST, HOWARD BEACH, NY 11414
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:RAGANO,GIOVANNA  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Healthfirst Inc New York, 25 Broadway 9th Floor, New York, NY 10004
    Copay:   Subscriber No:PC51279Y   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 14:24:19 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Martinez, Shaun   DOB:06/28/1987 Tel:347-331-7775 SSN:  Sex: M

   Address:8838 239TH ST, BELLEROSE, NY, US 11426
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Martinez,Shaun  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

POPOV, MAX   DOB:08/02/1997 Tel:202-779-8203 SSN:  Sex: M

   Address:2018 HARMAN ST, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:POPOV,MAX  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Healthfirst Inc New York, 25 Broadway 9th Floor, New York, NY 10004
    Copay:   Subscriber No:YG45214V   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes notesEligibility :2021-11-09 @ 14:38:31 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

STODDARD, GRIFFIN   DOB:09/15/1995 Tel:206-321-0061 SSN:  Sex: M

   Address:957 GREENE AVE, BROOKLYN, NY 11221
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:STODDARD,GRIFFIN  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

SHANTZ, ATTICUS G   DOB:12/27/1995 Tel:206-307-1245 SSN:  Sex: M

   Address:1712 1/2 N 36TH, SEATTLE, WA 98103
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:SHANTZ,ATTICUS G 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Molina Medicare Options HMO, PO Box 22811, Long Beach, CA 90801
    Copay:   Subscriber No:100000377393   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Sawh, Anastasia A   DOB:04/11/1993 Tel:347-320-9166 SSN:  Sex: F

   Address:89 CARSTAIRS RD, VALLEY STREAM, NY 11581-3318
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Sawh,Anastasia A 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:FMO805237309   Group No:37328
   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing 20 1 1.00 $100.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 15:04:58 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Shakoor, Sharda   DOB:11/08/1969 Tel:347-334-9091 SSN:  Sex: F

   Address:10708 107th St, Fl 1, OZONE PARK, NY 11417
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Shakoor,Sharda  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:jlj727295943   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing 20 1 1.00 $100.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 15:04:49 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Lucas, Karen   DOB:08/22/1984 Tel:347-845-9179 SSN:  Sex: F

   Address:1710 Linden Street 3r, Ridgewood, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Lucas,Karen  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Healthfirst Inc New York, 25 Broadway 9th Floor, New York, NY 10004
    Copay:   Subscriber No:RU72689A   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

notesEligibility :2021-11-09 @ 14:59:47 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 14:59:30

EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 14:59:30 EST : Eligible : Eligible; notesEligibility
Notes :2021-11-09 @ 14:59:29 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 14:59:29 EST : Eligible :
Eligible; notesEligibility :2021-11-09 @ 14:59:28 EST : Eligible : Eligible; notesEligibility :2021-11-09 @
14:59:25 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 14:59:25 EST : Eligible : Eligible;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

GARCIA, KYLANIE R   DOB:07/03/2016 Tel:347-845-9179 SSN:  Sex: F

   Address:1710 LINDEN ST, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:GARCIA,KYLANIE R 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Healthfirst Inc New York, 25 Broadway 9th Floor, New York, NY 10004
    Copay:   Subscriber No:KG48360R   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 14:59:08 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Agate, Alisha   DOB:06/06/1990 Tel:718-450-6277 SSN:  Sex: F

   Address:7008 Central Ave, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Agate,Alisha  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Fidelis Care New York, PO Box 8052, Amherst, NY 14226
    Copay:   Subscriber No:74033414000   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. S60.222A Contusion of left hand, initial encounter (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 20 1 1.00 $172.00
  73130 X-RAY EXAM OF HAND 20 1 1.00 $77.00

notesEligibility :2021-11-09 @ 15:04:44 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 15:04:35

Notes
EST : Eligible : Eligible;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Kaminski, Piotr   DOB:04/07/1974 Tel:347-584-6608 SSN:  Sex: M

   Address:454 FISH HILL RD, TANNERSVILLE, PA 18372-7758
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Kaminski,Piotr  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  36415 VENIPUNCT, ROUTINE* 20 1 1.00 $30.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

VANDERGRIENDT, NATASHA C   DOB:02/18/1975 Tel:973-220-5868 SSN:  Sex: F

   Address:64 PHEASANT HILL DR, FAR HILLS, NJ 07931-2509
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:VANDERGRIENDT,NATASHA C 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:HRH451A24471   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 15:04:34 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

CARUSO, THOMAS   DOB:09/12/1957 Tel:347-538-3520 SSN:  Sex: M

   Address:28 GRANT PL, GLEN COVE, NY 11542
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:CARUSO,THOMAS  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. UNITED HEALTH CARE, PO BOX 740800, ATLANTA, GA 30374-0484
    Copay:   Subscriber No:914112129   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  36415 VENIPUNCT, ROUTINE* 20 1 1.00 $30.00

Notes notesEligibility :2021-11-09 @ 15:11:46 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Joseph, Gullo Joglar   DOB:02/18/2016 Tel:347-938-5241 SSN:  Sex: M

   Address:5549 METROPOLITAN AVE, RIDGEWOOD, NY, US 11385-1202
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia

Responsible Party Name:Joseph,Gullo Joglar  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Healthfirst Inc New York, 25 Broadway 9th Floor, New York, NY 10004
    Copay:   Subscriber No:kn57619b   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. B34.9 Viral syndrome   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822B34.9 20 1 1.00 $172.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00
  87880 STREP A ASSAY W/OPTIC 20 1 1.00 $25.00

notesEligibility :2021-11-09 @ 15:16:57 EST : Cannot Process; notesEligibility :2021-11-09 @ 15:16:54

EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 15:16:47 EST : Eligible : Eligible; notesEligibility
Notes
:2021-11-09 @ 15:16:46 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 15:16:43 EST : Eligible :
Eligible;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

COHETERO, CHRISTOPHE   DOB:02/22/2012 Tel:347-279-1088 SSN:  Sex: M

   Address:1719 PALMETTO ST, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:COHETERO,CHRISTOPHE  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. MetroPlus Health Plan, PO Box 1966, New York, NY 10116
    Copay:   Subscriber No:ND69518W   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

notesEligibility :2021-11-09 @ 15:57:14 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 15:57:14

Notes EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 15:57:12 EST : Eligible : Eligible; notesEligibility
:2021-11-09 @ 15:57:09 EST : Eligible : Eligible;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

SALAS, CAMILA COHETERO   DOB:10/27/2014 Tel:347-279-1088 SSN:  Sex: F

   Address:1719 PALMETTO ST, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:SALAS,CAMILA COHETERO  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. MetroPlus Health Plan, PO Box 1966, New York, NY 10116
    Copay:   Subscriber No:KZ28998Q   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 15:57:29 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Mayorga, David   DOB:08/14/1981 Tel:516-439-0086 SSN:  Sex: M

   Address:6217 COOPER AVE, RIDGEWOOD, NY, US 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Mayorga,David  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. MetroPlus Health Plan, PO Box 1966, New York, NY 10116
    Copay:   Subscriber No:000026016   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 15:34:23 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Lopera, Eliana   DOB:08/15/1993 Tel:718-314-2846 SSN:  Sex: F

   Address:1731 MENAHAN ST, 1, RIDGEWOOD, NY 11385-2136
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Lopera,Eliana  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Emblem Health, PO BOX 3000, NY, NY 10116-3000
    Copay:   Subscriber No:K6052086701   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

notesEligibility :2021-11-09 @ 15:58:50 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 15:57:19

Notes
EST : InEligible;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Pellerito, Cosima   DOB:02/27/1962 Tel:347-739-6722 SSN:  Sex: F

   Address:6042 MENAHAN ST, RIDGEWOOD, NY, US 11385-2626
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Pellerito,Cosima  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:ETRBJ0788409   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. H60.501 Acute otitis externa of right ear, unspecified type   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822H60.501 20 1 1.00 $172.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 16:07:46 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Salazar, Isaac   DOB:02/11/2004 Tel:917-468-0420 SSN:  Sex: M

   Address:6852 78TH ST, MIDDLE VILLAGE, NY 11379-2831
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Salazar,Isaac  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Aetna, PO BOX 14079, LEXINGTON, KY 40512
    Copay:15.00   Subscriber No:w231883710   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 16:05:16 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

GONZALEZ, GLORIA   DOB:05/25/1935 Tel:646-303-7230 SSN:  Sex: F

   Address:7533 60TH PL, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:GONZALEZ,GLORIA  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Medicare, PO Box 4751, Syracuse, NY 13221
    Copay:   Subscriber No:582468106A   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. L02.91 Abscess (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 L02.91 20 1 1.00 $172.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Capitelli, Joseph   DOB:03/28/2001 Tel:718-416-0016 SSN:  Sex: M

   Address:6411 71st Street, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Capitelli,Joseph  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:mky3hzn78174620   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. J01.90 Acute non-recurrent sinusitis, unspecified location   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822J01.90 20 1 1.00 $172.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 16:15:52 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Davis, Sy   DOB:08/02/2018 Tel:310-766-8048 SSN:  Sex: M

   Address:2108 Rene Ct, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Davis,Sy  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Aetna, PO BOX 14079, LEXINGTON, KY 40512
    Copay:   Subscriber No:w232259868   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 16:09:38 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

RODRIGUEZ, SARAI   DOB:04/05/1992 Tel:347-681-3607 SSN:  Sex: F

   Address:10117 AVENUE K, BROOKLYN, NY 11236-4429
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:RODRIGUEZ,SARAI  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Emblem Health, PO BOX 3000, NY, NY 10116-3000
    Copay:   Subscriber No:K9069072101   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 16:42:01 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

CUADRADO, MELANIE   DOB:08/13/2010 Tel:718-840-7824 SSN:  Sex: F

   Address:69 BUSHWICK AVE, BROOKLYN, NY 11211
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:CUADRADO,MELANIE  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Aetna, PO BOX 14079, LEXINGTON, KY 40512
    Copay:   Subscriber No:W226555200   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 16:33:36 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

MURILLO, JENNIFER   DOB:07/04/1988 Tel:718-840-7824 SSN:  Sex: F

   Address:69 BUSHWICK AVE, BROOKLYN, NY 11211
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:MURILLO,JENNIFER  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Aetna, PO BOX 14079, LEXINGTON, KY 40512
    Copay:   Subscriber No:W226555200   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 16:32:38 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

CACIOPPO, JOSEPH   DOB:07/18/1978 Tel:347-997-2269 SSN:  Sex: M

   Address:7505 69TH RD, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:CACIOPPO,JOSEPH  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Empire Plan, P O Box 1600, kingston, ny 12402
    Copay:   Subscriber No:UES593W06398   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Verderber, Marie   DOB:03/21/1961 Tel:718-986-6281 SSN:  Sex: F

   Address:7020 65TH ST, RIDGEWOOD, NY, US 11385-6261
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Verderber,Marie  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Empire Plan, P O Box 1600, kingston, ny 12402
    Copay:30.00   Subscriber No:890466152   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes notesEligibility :2021-11-09 @ 16:47:06 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Merritt, Jennifer   DOB:11/19/1973 Tel:917-662-8040 SSN:  Sex: F

   Address:6259 FOREST AVE, APT 2A, RIDGEWOOD, NY, US 11385-2347
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Merritt,Jennifer  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Healthfirst Inc New York, 25 Broadway 9th Floor, New York, NY 10004
    Copay:   Subscriber No:ZW85524G   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  36415 VENIPUNCT, ROUTINE* 20 1 1.00 $30.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

MELENDEZ, ASHLEY   DOB:10/06/1998 Tel:929-363-8954 SSN:  Sex: F

   Address:1874 DEKALB AVE, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:MELENDEZ,ASHLEY  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. 1199 Local Benefit Fund, PO Box 1007, New York, NY 10108
    Copay:   Subscriber No:9023082772   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. B34.9 Viral syndrome   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822B34.9 20 1 1.00 $172.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

REYES, JUNIOR   DOB:02/20/1976 Tel:917-428-7138 SSN:  Sex: M

   Address:1043 MYRTLE AVE, BROOKLYN, NY 11206
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:REYES,JUNIOR  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Healthfirst Inc New York, 25 Broadway 9th Floor, New York, NY 10004
    Copay:   Subscriber No:UE89382X   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z23 Encounter for immunization   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  91300 PFIZER VACCINE Z20.822 20 80 1.00
  0001A ADM SARSCOV2 30MCG/0.3ML 1ST Z20.822 20 1.00
   COVID- 19 PFIZER 1.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

POPIC, ZORANA   DOB:03/02/1972 Tel:917-885-2093 SSN:  Sex: F

   Address:711 146TH ST, FLUSHING, NY 11367-2063
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:POPIC,ZORANA  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:KJVM12089860   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes notesEligibility :2021-11-09 @ 17:23:18 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Lucius, Jereime   DOB:06/25/1993 Tel:347-377-1157 SSN:  Sex: M

   Address:1444 E 86TH ST, Middle Village, NY 11236
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Lucius,Jereime  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. 1199 Local Benefit Fund, PO Box 1007, New York, NY 10108
    Copay:   Subscriber No:9800631869   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1.
Accident caused by hypodermic needle, initial encounter (primary)  
W46.0XXA
2. T14.8XXA Puncture wound   

Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units Billed Fee

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Arroyo, Darlene   DOB:04/12/1966 Tel:917-750-4081 SSN:  Sex: F

   Address:6811 FOREST AVE, 2R, RIDGEWOOD, NY 11385-4451
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Arroyo,Darlene  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:mbwan6019138   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. B34.9 Viral syndrome   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822B34.9 20 1 1.00 $172.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 17:22:34 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

BATTIPAGLIA, CHRISTINA   DOB:01/27/1994 Tel:516-325-0106 SSN:  Sex: F

   Address:7816 268TH ST, GLEN OAKS, NY 11004-1331
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:BATTIPAGLIA,CHRISTINA  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:DJL000082227   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

notesEligibility :2021-11-09 @ 17:25:40 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 17:25:39

Notes
EST : Eligible : Eligible;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

BATTIPAGLIA, DANIELLA   DOB:12/10/2002 Tel:347-482-9289 SSN:  Sex: F

   Address:7816 268TH ST, GLEN OAKS, NY 11004
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:BATTIPAGLIA,DANIELLA  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Fidelis Care New York, PO Box 8052, Amherst, NY 14226
    Copay:   Subscriber No:74452243800   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. S60.011A Contusion of right thumb without damage to nail, initial encounter   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 S60.012A 20 1 1.00 $172.00
  73140 X-RAY EXAM OF FINGER(S) 20 1 1.00 $79.00

notesEligibility :2021-11-09 @ 17:28:10 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 17:28:10

Notes
EST : Eligible : Eligible;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

MALESEVIC, JOVO   DOB:11/04/1961 Tel:646-553-9370 SSN:  Sex: M

   Address:407 E 81ST ST, APT 5B, New York, NY 10028
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:MALESEVIC,JOVO  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:ETRBJ2366424   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes notesEligibility :2021-11-09 @ 17:33:30 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Karpinska, Julita   DOB:03/01/1972 Tel:718-864-3457 SSN:  Sex: F

   Address:1, 6048 Myrtle Ave, RIDGEWOOD, NY, US 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Karpinska,Julita  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Karpinska, Jakob   DOB:07/11/2010 Tel:718-864-3457 SSN:  Sex: M

   Address:6048 MYRTLE AVE, RIDGEWOOD, NY 11385-5907
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Karpinska,Jakob  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Fidelis Care New York, PO Box 8052, Amherst, NY 14226
    Copay:   Subscriber No:744384365-00   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Tipan, Carla   DOB:05/12/1982 Tel:646-633-3960 SSN:  Sex: F

   Address:1023 LAFAYETTE AVE, APT 4D, BROOKLYN, NY 11221-2390
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Tipan,Carla  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. UNITED HEALTH CARE, PO BOX 740800, ATLANTA, GA 30374-0484
    Copay:   Subscriber No:072827000   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Pesantez, Amee   DOB:07/13/2006 Tel:646-633-3960 SSN:  Sex: F

   Address:1023 LAFAYETTE AVE, APT 4D, BROOKLYN, NY 11221-2390
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Pesantez,Amee  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Aetna, PO BOX 14079, LEXINGTON, KY 40512
    Copay:   Subscriber No:w055541197   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Cangui Aguirre, Rosario D   DOB:09/24/1959 Tel:646-633-3960 SSN:  Sex: F

   Address:1023 LAFAYETTE AVE, APT 4D, BROOKLYN, NY 11221-2390
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Cangui Aguirre,Rosario D 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Aetna, PO BOX 14079, LEXINGTON, KY 40512
    Copay:   Subscriber No:w08021779   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

ROSA, GWENDALYN   DOB:10/12/2002 Tel:917-615-2058 SSN:  Sex: F

   Address:5840 VCATALPA AVE, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:ROSA,GWENDALYN  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Emblem Health, PO BOX 3000, NY, NY 10116-3000
    Copay:   Subscriber No:K9046912303   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. R21 Rash (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 R21 20 1 1.00 $172.00

Co-Pay Paid 50.00   Credit Card

Notes notesEligibility :2021-11-09 @ 17:46:47 EST : Eligible : Eligible;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Czarny, Arkadiusz R   DOB:02/09/1988 Tel:347-476-7852 SSN:  Sex: M

   Address:9705 103RD AVE, OZONE PARK, NY 11417-1610
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Czarny,Arkadiusz R 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Zasonski, Krystian   DOB:07/10/1994 Tel:347-619-7917 SSN:  Sex: M

   Address:6441 60TH RD, MASPETH, NY 11378-3432
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Zasonski,Krystian  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Valle, Leilani   DOB:02/27/2007 Tel:718-807-8732 SSN:  Sex: F

   Address:7709 Eliot Ave, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Valle,Leilani  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:twqtwf608377   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. J02.9 Acute pharyngitis   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822J02.9 20 1 1.00 $172.00
  87880 STREP A ASSAY W/OPTIC 20 1 1.00 $25.00
  87880 STREP A ASSAY W/OPTIC 20 1 1.00 $25.00
  87880 STREP A ASSAY W/OPTIC 20 1 1.00 $25.00
  87880 STREP A ASSAY W/OPTIC 20 1 1.00 $25.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Naveja, Jean M   DOB:03/12/1985 Tel:718-807-8732 SSN:  Sex: F

   Address:7709 ELIOT AVE, MIDDLE VILLAGE, NY, US 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Naveja,Jean M 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Luciano, Elissa   DOB:08/16/2004 Tel:917-678-0009 SSN:  Sex: F

   Address:6439 ADMIRAL AVE, MIDDLE VILLAGE, NY 11379-1613
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Luciano,Elissa  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. OXFORD, PO BOX 29130, HOT SPRINGS, AR 71903-9041
    Copay:25.00   Subscriber No:48466705401   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. J02.9 Acute pharyngitis   
3. B34.9 Viral syndrome   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822J02.9 B34.9 20 1 1.00 $172.00
  87880 STREP A ASSAY W/OPTIC 20 1 1.00 $25.00
  87880 STREP A ASSAY W/OPTIC 20 1 1.00 $25.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 18:01:28 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

CORA, MARCOS A   DOB:07/19/1981 Tel:917-903-2729 SSN:  Sex: M

   Address:6114 COOPER AVE, FL 1, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:CORA,MARCOS A 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. MetroPlus Health Plan, PO Box 1966, New York, NY 10116
    Copay:   Subscriber No:630414190   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

notesEligibility :2021-11-09 @ 18:21:33 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 18:21:29

EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 18:21:28 EST : Eligible : Eligible; notesEligibility
Notes
:2021-11-09 @ 18:21:23 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 18:21:22 EST : Eligible :
Eligible; notesEligibility :2021-11-09 @ 18:21:19 EST : Eligible : Eligible;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

CORA, DYLAN   DOB:03/31/2005 Tel:917-903-2729 SSN:  Sex: M

   Address:6114 COOPER AVE, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:CORA,DYLAN  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Healthfirst Inc New York, 25 Broadway 9th Floor, New York, NY 10004
    Copay:   Subscriber No:921875302   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 18:21:01 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

FERNANDEZ, ISRAEL   DOB:07/23/1983 Tel:917-496-0412 SSN:  Sex: M

   Address:240 E MAIN ST, STE F, PATCHOGUE, NY 11772
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:FERNANDEZ,ISRAEL  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Healthfirst Inc New York, 25 Broadway 9th Floor, New York, NY 10004
    Copay:   Subscriber No:420000019093300   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes notesEligibility :2021-11-09 @ 18:17:08 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Sokolowska, Magdalena   DOB:06/18/1975 Tel:718-877-4323 SSN:  Sex: F

   Address:6006 56TH DR, MASPETH, NY, US 11378-2317
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia

Responsible Party Name:Sokolowska,Magdalena  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Cigna, PO Box 188055, Chattanooga, TN 37422
    Copay:20.00   Subscriber No:U4560743802   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. R10.13 Epigastric pain (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 20 1 1.00 $172.00

Co-Pay Paid 0.00   Cash

Co-Pay Paid 50.00   Credit Card
notesEligibility :2021-11-09 @ 18:37:05 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 18:37:05
Notes
EST : Eligible : Eligible;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

BOODHOO, ZAHEER   DOB:07/24/1994 Tel:516-270-6542 SSN:  Sex: M

   Address:71-12 70TH ST, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:BOODHOO,ZAHEER  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:T7N630W06907   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  36415 VENIPUNCT, ROUTINE* 20 1 1.00 $30.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 18:37:37 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

RAZUMOVA, MARINA   DOB:07/29/1988 Tel:214-642-4421 SSN:  Sex: F

   Address:5924 67TH AVE, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:RAZUMOVA,MARINA  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Anthem, 165 BROADWAY, NEW YORK, NY 10006-1404
    Copay:   Subscriber No:JQU479W08805   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. H60.501 Acute otitis externa of right ear, unspecified type (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 H60.501 20 1 1.00 $172.00

Co-Pay Paid 50.00   Credit Card

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Da Silva, Dylan J   DOB:04/02/1990 Tel:845-239-2112 SSN:  Sex: M

   Address:7104 FRESH POND RD, RIDGEWOOD, NY 11385-5905
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Da Silva,Dylan J 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

SANCHEZ, JACKELINE   DOB:07/08/1971 Tel:347-863-4987 SSN:  Sex: F

   Address:8 DELTA COURT, NORTH BRUNSWICK, NJ 08902
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:SANCHEZ,JACKELINE  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:L9V518W02639   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes notesEligibility :2021-11-09 @ 19:07:23 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Monterroso, Nathaly   DOB:02/12/1984 Tel:347-493-6290 SSN:  Sex: F

   Address:6049 55TH ST, MASPETH, NY 11378-3357
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Monterroso,Nathaly  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Medicaid of New York Computer Science C, PO Box 4601, Rensselaer, NY 12144
    Copay:   Subscriber No:yg61488p   Group No:

   
Insured's relation to patient:Self - patient is the insured
2. MetroPlus Health Plan, PO Box 1966, New York, NY 10116
    Copay:   Subscriber No:630330253   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

PENAFIEL, DIEGO   DOB:07/04/1984 Tel:917-684-2020 SSN:  Sex: M

   Address:3229 95TH ST, EAST ELMHURST, NY 11369
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:PENAFIEL,DIEGO  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. MetroPlus Health Plan, PO Box 1966, New York, NY 10116
    Copay:   Subscriber No:RA34176S   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Caraballo, Jamie   DOB:12/21/1976 Tel:718-386-6361 SSN:  Sex: F

   Address:2R, 2010 Palmetto Str, RIDGEWOOD, NY, US 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia

Responsible Party Name:Caraballo,Jamie  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. MagnaCare, PO BOX 1001, GARDEN CITY, NY 11530
    Copay:   Subscriber No:0000006318   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. S93.401A Sprain of right ankle, unspecified ligament, initial encounter (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 S93.401A 20 1 1.00 $172.00
  73610 X-RAY EXAM OF ANKLE 20 1 1.00 $76.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

ALIBASIC, FATMIRE   DOB:02/04/1998 Tel:347-247-4191 SSN:  Sex: F

   Address:1874 CORNELIA ST, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:ALIBASIC,FATMIRE  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:ETRBJ0729865   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 19:15:59 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

LUCAS, MIGUEL G   DOB:04/01/1972 Tel:917-495-0053 SSN:  Sex: M

   Address:6049 55TH ST, MASPETH, NY 11378
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:LUCAS,MIGUEL G 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. MetroPlus Health Plan, PO Box 1966, New York, NY 10116
    Copay:   Subscriber No:RK48440M   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

LUCAS, MIGUEL   DOB:01/03/2008 Tel:347-493-6290 SSN:  Sex: M

   Address:6049 55TH ST, MASPETH, NY 11378
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:LUCAS,MIGUEL  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. MetroPlus Health Plan, PO Box 1966, New York, NY 10116
    Copay:   Subscriber No:RK48440M   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

LUCAS, AARON   DOB:06/25/2013 Tel:347-493-6290 SSN:  Sex: M

   Address:6049 55TH ST, MASPETH, NY 11378
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:LUCAS,AARON  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. MetroPlus Health Plan, PO Box 1966, New York, NY 10116
    Copay:   Subscriber No:KX28749R   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Adames, Priscilla   DOB:01/20/1982 Tel:718-600-0100 SSN:105-66-0284  Sex: F

   Address:315 E 102ND ST, APT 825, NEW YORK, NY 10029-5681
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Adames,Priscilla  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. MetroPlus Health Plan, PO Box 1966, New York, NY 10116
    Copay:   Subscriber No:630383545   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

notesEligibility :2021-11-09 @ 19:31:34 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 19:31:33

Notes
EST : Eligible : Eligible;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

MORRISROE, THOMAS J   DOB:06/07/1949 Tel:718-628-7606 SSN:  Sex: M

   Address:6244 65TH ST, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:MORRISROE,THOMAS J 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Emblem Health, PO BOX 3000, NY, NY 10116-3000
    Copay:   Subscriber No:K4026319901   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z23 Encounter for immunization   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  91301 COVID 19 Vaccination Z20.822 20 80 1.00
  0003a PFIZER Dose #3 Z20.822 20 80 1.00
   COVID- 19 PFIZER 1.00

Notes
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

ALESTRA, GABRIELLA M   DOB:06/24/1991 Tel:347-784-7461 SSN:  Sex: F

   Address:6505 79TH ST, MIDDLE VILLAGE, NY 11379-2716
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia

Responsible Party Name:ALESTRA,GABRIELLA M 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Cigna, PO Box 188055, Chattanooga, TN 37422
    Copay:   Subscriber No:U6510468601   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. B34.9 Viral syndrome   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822B34.9 20 1 1.00 $172.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00
  87880 STREP A ASSAY W/OPTIC 20 1 1.00 $25.00

Notes notesEligibility :2021-11-09 @ 19:45:18 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

VASSALLO, SAMANTHA M   DOB:11/07/1996 Tel:917-434-8448 SSN:  Sex: F

   Address:5818 74TH ST, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:VASSALLO,SAMANTHA M 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. UNITED HEALTH CARE, PO BOX 740800, ATLANTA, GA 30374-0484
    Copay:   Subscriber No:960744048   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822 20 1 1.00 $172.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 19:41:19 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Pesantez, Ariany   DOB:10/01/2003 Tel:646-633-3960 SSN:  Sex: F

   Address:1023 LAFAYETTE AVE, APT 4D, BROOKLYN, NY 11221-2390
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Pesantez,Ariany  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Aetna, PO BOX 14079, LEXINGTON, KY 40512
    Copay:   Subscriber No:w055541197   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes notesEligibility :2021-11-09 @ 20:07:07 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

TORRES MORAN, DAVIS   DOB:01/16/1969 Tel:347-737-3542 SSN:  Sex: M

   Address:5810 MASPETH AVE, MASPETH, NY 11378-2245
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:TORRES MORAN,DAVIS  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Fidelis Care New York, PO Box 8052, Amherst, NY 14226
    Copay:   Subscriber No:743731026-00   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 20:21:22 EST : Eligible : Eligible;

 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Castle, Jerome   DOB:11/10/1999 Tel:718-916-8634 SSN:  Sex: M

   Address:452 LOGAN ST, BROOKLYN, NY 11208-2518
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Castle,Jerome  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. MetroPlus Health Plan, PO Box 1966, New York, NY 10116
    Copay:   Subscriber No:SE23380T   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. M25.561 Acute pain of right knee (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 20 1 1.00 $172.00
  73562 X-RAY EXAM OF KNEE, 3 20 1 1.00 $87.00

notesEligibility :2021-11-09 @ 20:40:04 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 20:39:59

EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 20:39:56 EST : Eligible : Eligible; notesEligibility
Notes
:2021-11-09 @ 20:39:55 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 20:39:55 EST : Eligible :
Eligible; notesEligibility :2021-11-09 @ 20:39:50 EST : Eligible : Eligible;
 Mompoint,Patricia

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Marquez, Jordan   DOB:11/18/2015 Tel:646-824-7194 SSN:  Sex: M

   Address:6056 FRESH POND RD, MASPETH, NY, US 11378-3544
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Mompoint,Patricia   
Assigned To : Schenker, Josef D

Responsible Party Name:Marquez,Jordan  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. MetroPlus Health Plan, PO Box 1966, New York, NY 10116
    Copay:   Subscriber No:000031456   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. R04.0 Bleeding from the nose (primary)  

2. R04.0 Epistaxis   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 20 1 1.00 $172.00

Co-Pay Paid 25.00   Credit Card

Notes notesEligibility :2021-11-09 @ 20:55:25 EST : Eligible : Eligible;
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Gonzalez, Delia   DOB:08/10/1970 Tel:917-375-1236 SSN:  Sex: F

   Address:6441 58TH RD, MASPETH, NY, US 11378-2805
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Gonzalez,Delia  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. BCBS Health Plus, PO BOX 61010, VIRGINIA BEACH, VA 23466-1010
    Copay:   Subscriber No:JlJ712692751   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. J01.90 Acute non-recurrent sinusitis, unspecified location (primary)  

2. Z20.822 Contact with and (suspected) exposure to covid-19   
3. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822Z20.828J01.90 20 1 1.00 $172.00
  87426 rapid covid testing Z20.822J01.90 Z20.828 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 09:05:02 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Alzate, Luis F   DOB:12/19/1969 Tel:917-468-0420 SSN:  Sex: M

   Address:6852 78th St, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Alzate,Luis F 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Aetna, PO BOX 14079, LEXINGTON, KY 40512
    Copay:   Subscriber No:w231883710   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Alzate, Liliana   DOB:03/16/1981 Tel:718-309-6838 SSN:  Sex: F

   Address:6852 78th St, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Alzate,Liliana  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Aetna, PO BOX 14079, LEXINGTON, KY 40512
    Copay:   Subscriber No:w231883710   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Guventurk, Altan   DOB:03/05/2001 Tel:718-458-4457 SSN:  Sex: M

   Address:6248 81ST ST, MIDDLE VILLAGE, NY 11379-1406
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Guventurk,Altan  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Aetna, PO BOX 14079, LEXINGTON, KY 40512
    Copay:30.00   Subscriber No:w093162576   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes notesEligibility :2021-11-09 @ 09:12:01 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

JANCZAK, BRIAN   DOB:06/17/2001 Tel:917-280-0081 SSN:  Sex: M

   Address:6418 75TH ST, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:JANCZAK,BRIAN  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:JLJ002300956   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99201 Office Visit, New Pt., Level 1 Z20.822Z20.828 20 1 1.00 $107.00

Notes notesEligibility :2021-11-09 @ 09:11:54 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

GLICKMAN, ADAM   DOB:08/31/1970 Tel:347-404-3188 SSN:  Sex: M

   Address:6637 60TH PL, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:GLICKMAN,ADAM  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Fidelis Care New York, PO Box 8052, Amherst, NY 14226
    Copay:   Subscriber No:74430924301   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99201 Office Visit, New Pt., Level 1 Z20.822 20 1 1.00 $107.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 09:25:15 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

ZENI, JOHN   DOB:06/21/1963 Tel:718-429-7844 SSN:  Sex: M

   Address:6052 71ST ST, MASPETH, NY 11378-2914
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:ZENI,JOHN  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. GHI New York, PO BOX 3000, NEW YORK, NY 10116-3000
    Copay:   Subscriber No:K9037234303   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 09:37:19 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Avolanti, Henry   DOB:03/26/1959 Tel:718-898-5721 SSN:  Sex: M

   Address:8229 Eliot Ave, MIDDLE VILLAGE, NY, US 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Avolanti,Henry  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:NEI801061016   Group No:P13346
   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes Laceration of finger of left hand without foreign body without damage to nail, unspecified
1. S61.219A
finger, initial encounter (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 S61.219A 20 1 1.00 $172.00
  73140 X-RAY EXAM OF FINGER(S) S61.219A 20 1 1.00 $79.00

Notes notesEligibility :2021-11-09 @ 09:51:12 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Nowak, Ewelina   DOB:03/25/1987 Tel:516-547-0556 SSN:  Sex: F

   Address:1715 LINDEN ST, RIDGEWOOD, NY 11385-2378
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Nowak,Ewelina  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. UNITED HEALTH CARE, PO BOX 740800, ATLANTA, GA 30374-0484
    Copay:   Subscriber No:102775334   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 09:43:58 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

FRANUSZKIEWICZ, TOMASZ M   DOB:11/17/1974 Tel:917-873-2350 SSN:  Sex: M

   Address:7109 67TH ST, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:FRANUSZKIEWICZ,TOMASZ M 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:NYB542W025528   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99201 Office Visit, New Pt., Level 1 Z20.822 20 1 1.00 $107.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

MACCHIARULO, MICHAEL   DOB:01/17/1992 Tel:347-236-9971 SSN:  Sex: M

   Address:6908 59TH DR, MASPETH, NY 11378
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:MACCHIARULO,MICHAEL  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. MagnaCare, PO BOX 1001, GARDEN CITY, NY 11530
    Copay:   Subscriber No:025884CA831   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. R56.9 Seizure (primary)  

2. F40.298 Needle phobia   
3. Z20.822 Contact with and (suspected) exposure to covid-19   
4. Z01.84 Encounter for antibody response examination   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822R56.9 F40.298Z01.84 20 1 1.00 $172.00
  36415 VENIPUNCT, ROUTINE* 20 1 1.00 $30.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Grayeb, Hamed   DOB:11/22/1963 Tel:917-544-9882 SSN:  Sex: M

   Address:7505 60TH PL, RIDGEWOOD, NY, US 11385-6044
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Grayeb,Hamed  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. J06.9 Viral URI (primary)  

2. Z20.822 Contact with and (suspected) exposure to covid-19   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822J06.9 20 1 1.00 $172.00
  87426 rapid covid testing Z20.822J06.9 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 09:34:43 EST : Cannot Process;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Vargas, Juan   DOB:09/16/1992 Tel:347-665-5044 SSN:  Sex: M

   Address:3l, 8419 51st Ave, ELMHURST, NY, US 11373
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Vargas,Juan  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. GHI New York, PO BOX 3000, NEW YORK, NY 10116-3000
    Copay:   Subscriber No:k9053693801   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. U07.1 COVID-19 (primary)  

2. Z20.822 Contact with and (suspected) exposure to covid-19   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 U07.1 Z20.822 20 1 1.00 $172.00
  87426 rapid covid testing Z20.822U07.1 20 1 1.00 $100.00

notesEligibility :2021-11-09 @ 09:36:22 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 09:36:22

EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 09:36:22 EST : Eligible : Eligible; notesEligibility
Notes :2021-11-09 @ 09:36:22 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 09:36:21 EST : Eligible :
Eligible; notesEligibility :2021-11-09 @ 09:36:21 EST : Eligible : Eligible; notesEligibility :2021-11-09 @
09:36:21 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 09:36:18 EST : Eligible : Eligible;
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Domitrz, Kinga   DOB:12/08/1982 Tel:917-699-4172 SSN:  Sex: F

   Address:6103 GROVE ST, 1, RIDGEWOOD, NY, US 11385-2603
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Domitrz,Kinga  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Emblem Health, PO BOX 3000, NY, NY 10116-3000
    Copay:   Subscriber No:K9066391701   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. A08.4 Viral gastroenteritis (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 A08.4 20 1 1.00 $172.00

Co-Pay Paid 50.00   Credit Card

notesEligibility :2021-11-09 @ 09:42:26 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 09:42:26
EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 09:42:25 EST : Eligible : Eligible; notesEligibility
Notes
:2021-11-09 @ 09:42:25 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 09:42:25 EST : Eligible :
Eligible; notesEligibility :2021-11-09 @ 09:42:21 EST : Eligible : Eligible;
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Gonzalez, Michael   DOB:12/01/1982 Tel:917-244-7443 SSN:  Sex: M

   Address:1913 Gates Ave #1l, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Gonzalez,Michael  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:20.00   Subscriber No:UES395W06399   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 09:55:31 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

MACANCELA, JONATHAN   DOB:07/07/2002 Tel:347-227-5014 SSN:  Sex: M

   Address:6060 68TH AVE, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:MACANCELA,JONATHAN  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:ETRBJ3064049   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99201 Office Visit, New Pt., Level 1 Z20.822 20 1 1.00 $107.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 09:49:10 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Alejandro, Danielle   DOB:11/13/1999 Tel:718-628-8983 SSN:  Sex: F

   Address:6730 CENTRAL AVE, RIDGEWOOD, NY, US 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Alejandro,Lisa  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Emblem Health, PO BOX 3000, NY, NY 10116-3000
    Copay:   Subscriber No:K9030852902   Group No:

   
Insured's Name:Alejandro,Lisa    
Insured's relation to patient:Natural Child - Insured has Financial Responsibility
    Insured's Address:2F, 6730 Central AVe, RIDGEWOOD, NY 11385

ICD-9 Codes 1. J02.0 Strep pharyngitis (primary)  

2. Z20.822 Contact with and (suspected) exposure to covid-19   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 J02.0 Z20.822 20 1 1.00 $172.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00
  87880 STREP A ASSAY W/OPTIC Z20.822J02.0 20 1 1.00 $25.00

Notes notesEligibility :2021-11-09 @ 10:07:47 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

FRIEDMAN, DANIELLE   DOB:06/14/1997 Tel:732-668-8823 SSN:  Sex: F

   Address:107 REDPINE LOOP, OLD BRIDGE, NJ 08857-3069
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:FRIEDMAN,DANIELLE  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Cigna, PO Box 188055, Chattanooga, TN 37422
    Copay:   Subscriber No:U6649941703   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. J02.9 Viral pharyngitis (primary)  

2. Z20.822 Contact with and (suspected) exposure to covid-19   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822J02.9 20 1 1.00 $172.00
  87880 STREP A ASSAY W/OPTIC Z20.822J02.9 20 1 1.00 $25.00
  87426 rapid covid testing Z20.822J02.9 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 10:19:24 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

FITZGERALD, ERIN F   DOB:06/15/1998 Tel:718-440-4360 SSN:  Sex: F

   Address:8004 CYPRESS HILLS, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:FITZGERALD,ERIN F 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. OXFORD, PO BOX 29130, HOT SPRINGS, AR 71903-9041
    Copay:   Subscriber No:67144915503   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. J06.9 Viral upper respiratory infection (primary)  

2. Z20.822 Contact with and (suspected) exposure to covid-19   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822J06.9 20 1 1.00 $172.00
  87426 rapid covid testing Z20.822J06.9 20 1 1.00 $100.00

notesEligibility :2021-11-09 @ 10:13:01 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 10:13:00

Notes
EST : Eligible : Eligible;
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

STANISAVLJEVIC, KRISTINA   DOB:04/21/1973 Tel:646-549-1832 SSN:  Sex: F

   Address:66-73 FOREST AVE, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Emblem Health, PO BOX 3000, NY, NY 10116-3000
    Copay:   Subscriber No:K9031281603   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

notesEligibility :2021-11-09 @ 10:13:54 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 10:13:53

Notes
EST : Eligible : Eligible;
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

PULLARA, JOSEPH   DOB:05/02/2000 Tel:917-327-1019 SSN:  Sex: M

   Address:7820 78TH ST, GLENDALE, NY 11385-7445
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:PULLARA,JOSEPH  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Emblem Health, PO BOX 3000, NY, NY 10116-3000
    Copay:   Subscriber No:K9042414703   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. J06.9 Viral upper respiratory infection (primary)  

2. Z20.822 Contact with and (suspected) exposure to covid-19   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822J06.9 20 1 1.00 $172.00
  87426 rapid covid testing Z20.822J06.9 20 1 1.00 $100.00

notesEligibility :2021-11-09 @ 10:19:48 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 10:19:39

EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 10:19:39 EST : Eligible : Eligible; notesEligibility
Notes :2021-11-09 @ 10:19:35 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 10:19:35 EST : Eligible :
Eligible; notesEligibility :2021-11-09 @ 10:19:12 EST : Cannot Process; notesEligibility :2021-11-09 @
10:19:12 EST : Cannot Process;
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

FILIMON, CORINA   DOB:12/31/1971 Tel:347-422-4673 SSN:  Sex: F

   Address:2033 PALMETTO ST, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:FILIMON,CORINA  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:JLJ718950639   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

notesEligibility :2021-11-09 @ 10:33:44 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 10:33:43

Notes
EST : Eligible : Eligible;
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Groh, Maggie   DOB:05/03/1999 Tel:504-314-8851 SSN:  Sex: F

   Address:220 Bill Kennedy Way Se, ATLANTA, GA 30316
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Groh,Maggie  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. UNITED HEALTH CARE, PO BOX 740800, ATLANTA, GA 30374-0484
    Copay:   Subscriber No:944916568   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99201 Office Visit, New Pt., Level 1 Z20.822Z20.828 20 1 1.00 $107.00

Notes notesEligibility :2021-11-09 @ 10:40:51 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Roccaforte, Lisa M   DOB:11/27/1968 Tel:917-443-1560 SSN:  Sex: F

   Address:7002 71ST PL, RIDGEWOOD, NY, US 11385-7327
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Roccaforte,Lisa M 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Affinity, PO Box 981650, El Paso, Tx 10701
    Copay:   Subscriber No:161105879   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 11:32:37 EST : Cannot Process;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

KOPETZ, SEAN   DOB:01/23/1995 Tel:603-552-0271 SSN:  Sex: M

   Address:345 PORTSMOUTH AVE, STRATHAM, NY 03885
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:KOPETZ,SEAN  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:YGQ841W07901   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99201 Office Visit, New Pt., Level 1 Z20.822Z20.828 20 1 1.00 $107.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

CEVALLOS, PATRICIA   DOB:05/17/1983 Tel:646-399-8386 SSN:  Sex: F

   Address:2122 ST, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:CEVALLOS,PATRICIA  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. R50.9 Fever, unspecified fever cause (primary)  

2. Z20.822 Contact with and (suspected) exposure to covid-19   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822R50.9 20 1 1.00 $172.00
  87426 rapid covid testing Z20.822R50.9 20 1 1.00 $100.00
  87804 INFLUENZA ASSAY W/OPTIC Z20.822R50.9 20 1 1.00 $50.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Schlosser, Michael L   DOB:10/08/1986 Tel:347-739-4285 SSN:  Sex: M

   Address:1915 WOODBINE ST, 2, RIDGEWOOD, NY 11385-3801
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Schlosser,Michael L 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:ues85480761   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Gonzalez, William S   DOB:01/05/1988 Tel:914-217-7087 SSN:  Sex: M

   Address:1943 Mayflower, BRONX, NY 10461
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Gonzalez,William S 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Emblem Health, PO BOX 3000, NY, NY 10116-3000
    Copay:   Subscriber No:k9026155301   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z23 Encounter for immunization   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  91300 PFIZER VACCINE Z20.822Z23 20 80 1.00
  0001A ADM SARSCOV2 30MCG/0.3ML 1ST Z20.822Z23 20 1.00
   COVID- 19 PFIZER Z20.822Z23 1.00

notesEligibility :2021-11-09 @ 11:02:32 EST : Cannot Process; notesEligibility :2021-11-09 @ 11:02:31

EST : Cannot Process; notesEligibility :2021-11-09 @ 11:01:30 EST : Cannot Process; notesEligibility
Notes
:2021-11-09 @ 11:01:29 EST : Cannot Process; notesEligibility :2021-11-09 @ 11:01:29 EST : Cannot
Process; notesEligibility :2021-11-09 @ 11:01:29 EST : Cannot Process;
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

BARTOLOMEY, CARRIE   DOB:02/22/1983 Tel:347-679-5334 SSN:  Sex: F

   Address:7353 70TH ST, MIDDLE VILLAGE, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:BARTOLOMEY,CARRIE  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z23 Encounter for immunization   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  91300 PFIZER VACCINE Z20.822 20 80 1.00
  0001A ADM SARSCOV2 30MCG/0.3ML 1ST Z20.822 20 1.00
   COVID- 19 PFIZER Z20.822 1.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

MARPMAN, MONIQUE M   DOB:05/06/1991 Tel:347-367-5125 SSN:  Sex: F

   Address:409 STANHOPE ST, BROOKLYN, NY 11237-4404
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:MARPMAN,MONIQUE M 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. UNITED HEALTH CARE, PO BOX 740800, ATLANTA, GA 30374-0484
    Copay:   Subscriber No:949009730   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Romero, Alyssa   DOB:12/22/2009 Tel:718-808-2530 SSN:  Sex: F

   Address:59-62 58TH AVE, MASPETH, NY, US 11378
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Romero,Sophia  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Velasquez, Nadiah   DOB:12/01/2011 Tel:718-808-2530 SSN:  Sex: F

   Address:5962 58TH AVE, MASPETH, NY, US 11378
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Velasquez,Marcos A 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

NUNEZ, CARLOS J   DOB:05/15/1996 Tel:929-412-6086 SSN:  Sex: M

   Address:551 W 190TH ST, NEW YORK, NY 10040-3560
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L   
Assigned To : Schenker, Josef D

Responsible Party Name:NUNEZ,CARLOS J 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Senior Care Pre Employment, 700 HAVEMEYER AVE, BRONX, NY 10473-1102
    Copay:   Subscriber No:123456789   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. V67.59 Encounter for PPD skin test reading (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99212 Office Visit, Est Pt., Level 2 V67.59 20 1 1.00 $75.00
  99455 Work Related Evaluation Services V67.59 20 1 1.00 $35.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

MANGONE, MELANIE J   DOB:08/27/1983 Tel:646-250-5093 SSN:  Sex: F

   Address:215 ESPLANADE, MAYWOOD, NJ 07607-1928
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:MANGONE,MELANIE J 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Cigna, PO Box 188055, Chattanooga, TN 37422
    Copay:   Subscriber No:U2142033901   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. R07.9 Chest pain, unspecified type (primary)  

2. R03.0 Elevated blood pressure reading   
3. Z20.822 Contact with and (suspected) exposure to covid-19   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 R07.9 R03.0 Z20.822 20 1 1.00 $172.00
  93000 -ELECTROCARDIOGRAM, COMPLETE R07.9 R03.0 20 1 1.00 $41.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 11:29:30 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Martinez, Adriana D   DOB:06/09/1995 Tel:929-321-4673 SSN:  Sex: F

   Address:7239 66TH PL, APT 2, RIDGEWOOD, NY 11385-6907
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Martinez,Adriana D 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:jlj718579733   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 11:44:39 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

AGUIRREMARTINEZ, SOPHIA A   DOB:11/21/2016 Tel:929-321-4673 SSN:  Sex: F

   Address:7239 66TH PL, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:AGUIRREMARTINEZ,SOPHIA A 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:JLJ723121674   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99201 Office Visit, New Pt., Level 1 Z20.822 20 1 1.00 $107.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

notesEligibility :2021-11-09 @ 11:44:32 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 11:44:31

Notes
EST : Eligible : Eligible;
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Acosta, Fernanda   DOB:05/15/1991 Tel:347-573-6110 SSN:  Sex: F

   Address:8419 51ST AVE, ELMHURST, NY 11373-5803
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Acosta,Fernanda  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. GHI New York, PO BOX 3000, NEW YORK, NY 10116-3000
    Copay:50.00   Subscriber No:k9053693803   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99212 Office Visit, Est Pt., Level 2 Z20.822 20 1 1.00 $105.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

notesEligibility :2021-11-09 @ 11:56:35 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 11:56:34

Notes
EST : Eligible : Eligible;
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

HAIRSTON, DAWAND   DOB:06/14/1983 Tel:347-558-7865 SSN:  Sex: M

   Address:17224 133RD AVE, JAMAICA, NY 11434
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:HAIRSTON,DAWAND  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Emblem Health, PO BOX 3000, NY, NY 10116-3000
    Copay:   Subscriber No:13939665   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes notesEligibility :2021-11-09 @ 12:08:11 EST : InEligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

ANDUJAR, LYDIA   DOB:07/18/1948 Tel:917-348-1020 SSN:  Sex: F

   Address:6426 WOODBINE ST, RIDGEWOOD, NY 11385-4654
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:ANDUJAR,LYDIA  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. United Healthcare Community Plan, POB OX 31348, Salt Lake City, UT 84131
    Copay:   Subscriber No:108082713   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 12:08:04 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

ANDUJAR, MARCIAL R   DOB:03/06/1949 Tel:917-348-1020 SSN:  Sex: M

   Address:6426 WOODBINE ST, RIDGEWOOD, NY 11385-4654
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:ANDUJAR,MARCIAL R 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Healthfirst Inc New York, 25 Broadway 9th Floor, New York, NY 10004
    Copay:   Subscriber No:124581307   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes notesEligibility :2021-11-09 @ 12:07:56 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

BARRANCO, NIKOLAS   DOB:09/07/2011 Tel:347-681-1512 SSN:  Sex: M

   Address:7131 69TH PL, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:BARRANCO,NIKOLAS  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Healthfirst Inc New York, 25 Broadway 9th Floor, New York, NY 10004
    Copay:   Subscriber No:NQ10287D   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 12:12:54 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Kelly, Rose   DOB:09/30/1972 Tel:347-790-8685 SSN:  Sex: F

   Address:6802 61ST RD, MIDDLE VILLAGE, NY, US 11379-1116
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Kelly,Rose  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. BCBS Health Plus, PO BOX 61010, VIRGINIA BEACH, VA 23466-1010
    Copay:   Subscriber No:JLJ723854669   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. J01.90 Acute sinusitis, recurrence not specified, unspecified location (primary)  
2. Z20.822 Contact with and (suspected) exposure to covid-19   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822J01.90 20 1 1.00 $172.00
  87426 rapid covid testing Z20.822J01.90 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 12:17:39 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Phillander, Qwami   DOB:08/14/2012 Tel:516-451-5752 SSN:  Sex: M

   Address:11013 FRANCIS LEWIS BLVD, QUEENS VILLAGE, NY 11429-1715
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Phillander,Qwami  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Healthfirst Inc New York, 25 Broadway 9th Floor, New York, NY 10004
    Copay:   Subscriber No:948817201   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. R10.9 Abdominal pain, unspecified abdominal location   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 20 1 1.00 $172.00
  87426 rapid covid testing 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 12:24:25 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Rivas, Jenny   DOB:04/23/1980 Tel:718-610-9670 SSN:  Sex: F

   Address:2049 Gates Ave Apt 3r, RIDGEWOOD, NY, US 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Rivas,Jenny  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:etrbj0796941   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   
3. R89.4 Influenza A virus not detected   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828R89.4 20 1 1.00 $51.00
  87804 INFLUENZA ASSAY W/OPTIC Z20.822 20 1 1.00 $50.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

MODANO, JOSEPHINE   DOB:12/07/1969 Tel:917-734-3072 SSN:  Sex: F

   Address:7515 65TH DR, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:MODANO,JOSEPHINE  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Emblem Health, PO BOX 3000, NY, NY 10116-3000
    Copay:   Subscriber No:K1015228602   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 12:54:44 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Tapia-santos, Xochitl M   DOB:09/08/1998 Tel:646-715-5521 SSN:  Sex: F

   Address:6109 60th Dr, MASPETH, NY 11378
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Tapia-santos,Xochitl M 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. UNITED HEALTH CARE, PO BOX 740800, ATLANTA, GA 30374-0484
    Copay:   Subscriber No:121043336   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. J06.9 Viral upper respiratory infection (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 J06.9 20 1 1.00 $172.00
  87880 STREP A ASSAY W/OPTIC J06.9 20 1 1.00 $25.00
  87804 INFLUENZA ASSAY W/OPTIC J06.9 20 1 1.00 $50.00

Co-Pay Paid 25.00   Cash

Notes notesEligibility :2021-11-09 @ 12:36:19 EST : Eligible : Eligible;
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Ocana, Richard   DOB:03/27/1994 Tel:347-369-3774 SSN:  Sex: M

   Address:1911 LINDEN ST, RIDGEWOOD, NY, US 11385-2314
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Ocana,Richard  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:w7g829281302   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 13:01:00 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Ramirez, Alexis   DOB:01/29/1986 Tel:347-739-0747 SSN:  Sex: F

   Address:6210 69th Pl #2, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Ramirez,Alexis  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Fidelis Care New York, PO Box 8052, Amherst, NY 14226
    Copay:   Subscriber No:74191664800   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. J06.9 Viral upper respiratory infection (primary)  

2. Z20.822 Contact with and (suspected) exposure to covid-19   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 J06.9 Z20.822 20 1 1.00 $172.00
  87426 rapid covid testing Z20.822J06.9 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 13:12:43 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Sikorski, Robert   DOB:02/08/2002 Tel:347-870-2583 SSN:  Sex: M

   Address:6626 54TH AVE, MASPETH, NY 11378-1615
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Sikorski,Robert  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:pgy267w02592   Group No:

   
Insured's relation to patient:Self - patient is the insured
2. UNITED HEALTH CARE, PO BOX 740800, ATLANTA, GA 30374-0484
    Copay:   Subscriber No:00000000   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Brown, Clyde W   DOB:06/17/1956 Tel:917-584-1683 SSN:  Sex: M

   Address:17212 133RD AVE, APT 10H, JAMAICA, NY 11434-3904
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Brown,Clyde W 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Emblem Health, PO BOX 3000, NY, NY 10116-3000
    Copay:   Subscriber No:k1008896201   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z23 Encounter for immunization   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  36415 VENIPUNCT, ROUTINE* U07.1 20 1 1.00 $30.00
  91301 COVID 19 Vaccination Z20.822 20 80 1.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00
  0003a PFIZER Dose #3 Z20.822 20 80 1.00
   COVID- 19 PFIZER 1.00

notesEligibility :2021-11-09 @ 13:17:37 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 13:16:26

Notes
EST : Eligible : Eligible;
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

ANTHONY, ARIEL   DOB:12/06/1988 Tel:917-402-1160 SSN:  Sex: M

   Address:5922 GROVE ST, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:ANTHONY,ARIEL  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. HIP, PO BOX 2845, NEW YORK, NY 10116
    Copay:   Subscriber No:K1012430201   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z23 Encounter for immunization   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  91301 COVID 19 Vaccination Z20.822 20 80 1.00
  0002A PFIZER dose 2 Z20.822 20 80 1.00
   COVID- 19 PFIZER 1.00

notesEligibility :2021-11-09 @ 15:08:34 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 15:08:34

EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 15:08:30 EST : Eligible : Eligible; notesEligibility
Notes
:2021-11-09 @ 15:08:30 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 15:08:30 EST : Eligible :
Eligible; notesEligibility :2021-11-09 @ 15:08:30 EST : Eligible : Eligible;
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Murray, Jovannie   DOB:03/03/1993 Tel:917-526-8327 SSN:  Sex: F

   Address:25103 139th Ave, ROSEDALE, NY 11422
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Murray,Jovannie  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. MetroPlus Health Plan, PO Box 1966, New York, NY 10116
    Copay:   Subscriber No:000034868   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. J06.9 Viral upper respiratory infection (primary)  

2. Z20.822 Contact with and (suspected) exposure to covid-19   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99203 Office Visit, New Pt., Level 3 J06.9 Z20.822 20 1 1.00 $258.00
  87426 rapid covid testing Z20.822J06.9 20 1 1.00 $100.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

KOWALEWSKI, ANNA   DOB:06/07/1983 Tel:646-657-5601 SSN:  Sex: F

   Address:7504 CALDWELL AVE, MIDDLE VILLAGE, NY 11379-5232
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:KOWALEWSKI,ANNA  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

DABROWSKI, THOMAS   DOB:09/24/1993 Tel:347-840-3516 SSN:  Sex: M

   Address:35 FLAGLER ST, D2, MORRISTOWN, NJ 07960
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:DABROWSKI,THOMAS  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:NSJ3HZN17933930   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99202 Office Visit, New Pt., Level 2 Z20.822Z20.828 20 1 1.00 $179.00

notesEligibility :2021-11-09 @ 13:33:22 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 13:33:20

EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 13:33:20 EST : Eligible : Eligible; notesEligibility
:2021-11-09 @ 13:33:20 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 13:33:19 EST : Eligible :
Notes Eligible; notesEligibility :2021-11-09 @ 13:33:17 EST : Eligible : Eligible; notesEligibility :2021-11-09 @
13:33:17 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 13:33:17 EST : Eligible : Eligible;
notesEligibility :2021-11-09 @ 13:33:17 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 13:33:17
EST : Eligible : Eligible;
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Byrne, Jennifer J   DOB:07/11/1973 Tel:347-891-2015 SSN:  Sex: F

   Address:6459 58th Rd, MASPETH, NY 11378
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Byrne,Jennifer J 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:MPR638A23921   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. J40 Bronchitis (primary)  

2. Z20.822 Contact with and (suspected) exposure to covid-19   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 Z20.822J40 20 1 1.00 $172.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 13:19:01 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Figueroa, HANNAH   DOB:10/15/2003 Tel:347-403-3909 SSN:  Sex: F

   Address:6118 68TH AVE, RIDGEWOOD, NY 11385-4628
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Figueroa,HANNAH  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. HIP, PO BOX 2845, NEW YORK, NY 10116
    Copay:   Subscriber No:K1010435903   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99212 Office Visit, Est Pt., Level 2 Z20.822 20 1 1.00 $105.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 15:08:52 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Banach, Krysyna   DOB:06/23/1960 Tel:646-399-2666 SSN:  Sex: F

   Address:2026 GATES AVE, RIDGEWOOD, NY 11385-3038
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Banach,Krysyna  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:jlj722636343   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes notesEligibility :2021-11-09 @ 14:02:41 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

BROCLAWIK, MILENA   DOB:11/10/2005 Tel:929-216-3969 SSN:  Sex: F

   Address:1864 HIMROD ST, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:BROCLAWIK,MILENA  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:JLJ719128708   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 15:08:08 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

STOPA, DYLAN   DOB:06/28/2003 Tel:917-902-0107 SSN:  Sex: M

   Address:6044 56TH DR, MASPETH, NY 11378
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:STOPA,DYLAN  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Fidelis Care New York, PO Box 8052, Amherst, NY 14226
    Copay:   Subscriber No:74273777100   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. R07.9 Chest pain, unspecified type (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99203 Office Visit, New Pt., Level 3 R07.9 20 1 1.00 $258.00

Notes notesEligibility :2021-11-09 @ 14:21:26 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Jovanovski, Ivan   DOB:08/12/1974 Tel:718-612-4441 SSN:  Sex: M

   Address:7216 67TH ST, APT 1R, RIDGEWOOD, NY 11385-6909
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Jovanovski,Ivan  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:SFW395W02550   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 14:24:11 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

REID, MARVIN   DOB:07/10/1982 Tel:718-775-1709 SSN:  Sex: M

   Address:13550 228TH ST, ROSEDALE, NY 11413
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:REID,MARVIN  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:HMT476W02544   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes notesEligibility :2021-11-09 @ 15:07:58 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Weiss, Robert   DOB:04/02/2014 Tel:646-510-1216 SSN:  Sex: M

   Address:7752 79TH PL, RIDGEWOOD, NY 11385-7538
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Weiss,Robert  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. BCBS Health Plus, PO BOX 61010, VIRGINIA BEACH, VA 23466-1010
    Copay:   Subscriber No:jlj718664383   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 15:07:44 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

GONZALEZ, KRISTIN J   DOB:02/20/1995 Tel:646-708-2185 SSN:  Sex: F

   Address:7752 79TH PL, GLENDALE, NY 11385-7538
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:GONZALEZ,KRISTIN J 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

RUIZ, CHRISTIAN   DOB:07/25/2001 Tel:516-713-4383 SSN:  Sex: M

   Address:454 LINDA DR, EAST MEADOW, NY 11554-2912
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:RUIZ,CHRISTIAN  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Emblem Health, PO BOX 3000, NY, NY 10116-3000
    Copay:   Subscriber No:K9040808502   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. J40 Bronchitis (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 J40 20 1 1.00 $75.00

Co-Pay Paid 50.00   Credit Card

notesEligibility :2021-11-09 @ 14:46:10 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 14:46:09
Notes EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 14:46:08 EST : Eligible : Eligible; notesEligibility
:2021-11-09 @ 14:46:05 EST : Eligible : Eligible;
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Barreto, Mellisa   DOB:12/19/1994 Tel:917-387-7082 SSN:  Sex: F

   Address:6039 53RD ST, MASPETH, NY, US 11378-3301
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Barreto,Mellisa  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. OXFORD, PO BOX 29130, HOT SPRINGS, AR 71903-9041
    Copay:   Subscriber No:19123721900   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 15:07:34 EST : Eligible : InEligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

LIM, FAREN   DOB:03/25/2002 Tel:347-345-7566 SSN:  Sex: F

   Address:5990 FRESH POND RD, APT# 2, MASPETH, NY 11378-3438
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:LIM,FAREN  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Aetna, PO BOX 14079, LEXINGTON, KY 40512
    Copay:   Subscriber No:W24757266402   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 14:50:55 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

CANTOR, EMMA   DOB:02/13/1997 Tel:917-743-0282 SSN:  Sex: F

   Address:322 W 87TH ST, NEW YORK, NY 10024
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:CANTOR,EMMA  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Aetna, PO BOX 14079, LEXINGTON, KY 40512
    Copay:   Subscriber No:W249249880   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00
  S9083 GLOBAL FEE URGENT CARE CENTERS Z20.822 20 1 1.00 $180.00

Notes notesEligibility :2021-11-09 @ 15:07:27 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

ARDEKANI, SOFIA-NOOR KRISTINA   DOB:05/11/1999 Tel:206-719-6184 SSN:  Sex: F

   Address:5614 90th Ave, MERCER ISLAND, NY 98040
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:ARDEKANI,SOFIA-NOOR KRISTINA  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99201 Office Visit, New Pt., Level 1 Z20.822Z20.828 20 1 1.00 $107.00
  87426 rapid covid testing Z20.822Z20.828 20 1 1.00 $100.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Rodriguez, Belia   DOB:04/18/1959 Tel:718-381-9257 SSN:  Sex: F

   Address:6050 56TH ST, APT 1R, MASPETH, NY 11378-3361
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Rodriguez,Belia  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:10.00   Subscriber No:FBH848039084508   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

notesEligibility :2021-11-09 @ 15:22:58 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 15:22:58

Notes
EST : Eligible : Eligible;
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Rodriguez, Ismael   DOB:04/01/1960 Tel:718-381-9257 SSN:  Sex: M

   Address:6050 56TH ST, APT 1R, MASPETH, NY 11378-3361
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Rodriguez,Ismael  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:fbh848039084508   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes notesEligibility :2021-11-09 @ 15:22:38 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Plonski, Dariusz   DOB:06/10/1976 Tel:917-337-1574 SSN:  Sex: M

   Address:7859 80TH ST, GLENDALE, NY 11385-7630
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Plonski,Dariusz  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. UNITED HEALTH CARE, PO BOX 740800, ATLANTA, GA 30374-0484
    Copay:   Subscriber No:02406780800   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  36415 VENIPUNCT, ROUTINE* Z20.822 20 1 1.00 $30.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 15:19:31 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

WHITE, ADDISON   DOB:06/29/1991 Tel:646-436-7555 SSN:  Sex: F

   Address:1642 CORNELIA ST, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:WHITE,ADDISON  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Anthem, 165 BROADWAY, NEW YORK, NY 10006-1404
    Copay:   Subscriber No:NSA01059437H   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes notesEligibility :2021-11-09 @ 15:30:46 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

WHITE, EZER   DOB:10/20/2018 Tel:646-436-7555 SSN:  Sex: F

   Address:1642 CORNELIA ST, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:WHITE,EZER  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Anthem, 165 BROADWAY, NEW YORK, NY 10006-1404
    Copay:   Subscriber No:NSA01059437H   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

notesEligibility :2021-11-09 @ 15:35:30 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 15:35:30

EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 15:35:29 EST : Eligible : Eligible; notesEligibility
Notes
:2021-11-09 @ 15:35:29 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 15:35:29 EST : Eligible :
Eligible;
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

DAVIS, MADISON J   DOB:03/13/1994 Tel:740-803-3618 SSN:  Sex: F

   Address:1933 GATES AVE, RIDGEWOOD, NY 11385-2434
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:DAVIS,MADISON J 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Healthfirst Inc New York, 25 Broadway 9th Floor, New York, NY 10004
    Copay:   Subscriber No:KY18956R   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 15:57:53 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Feliciano, Justin   DOB:07/04/2007 Tel:718-593-7412 SSN:  Sex: M

   Address:6239 69TH PL, MIDDLE VILLAGE, NY, US 11379-1107
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Feliciano,Justin  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:etrbj0777842   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 16:00:35 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Kava, Alexa M   DOB:12/05/1997 Tel:917-648-0418 SSN:  Sex: F

   Address:6019 61ST ST, MASPETH, NY, US 11378-3519
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Kava,Alexa M 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. HIP, PO BOX 2845, NEW YORK, NY 10116
    Copay:5.00   Subscriber No:K1005075603   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. J01.90 Acute non-recurrent sinusitis, unspecified location (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 J01.90 20 1 1.00 $172.00

Co-Pay Paid 10.00   Credit Card

notesEligibility :2021-11-09 @ 15:53:25 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 15:53:25
EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 15:53:25 EST : Eligible : Eligible; notesEligibility
Notes
:2021-11-09 @ 15:53:25 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 15:53:25 EST : Eligible :
Eligible;
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Minutello, Erin   DOB:02/15/1979 Tel:347-813-7664 SSN:  Sex: F

   Address:5827 58th Rd, MASPETH, NY 11378
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Minutello,Erin  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Fidelis Care New York, PO Box 8052, Amherst, NY 14226
    Copay:   Subscriber No:74437300200   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 15:56:49 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Rodriguez, Cynthia   DOB:12/25/1983 Tel:813-546-2855 SSN:  Sex: F

   Address:2117 RENE CT, RIDGEWOOD, NY 11385-1225
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Rodriguez,Cynthia  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. HIP, PO BOX 2845, NEW YORK, NY 10116
    Copay:50.00   Subscriber No:k1009230001   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 16:05:26 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Sakic, Michael   DOB:01/26/1988 Tel:347-262-8081 SSN:  Sex: M

   Address:5921 PALMETTO STR, RIDGEWOOD, NY, US 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Sakic,Michael  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Healthfirst Inc New York, 25 Broadway 9th Floor, New York, NY 10004
    Copay:   Subscriber No:WW53257V   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z23 Need for Tdap vaccination (primary)  

2. Z23 Encounter for immunization   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99212 Office Visit, Est Pt., Level 2 Z23 Z23 20 1 1.00 $105.00
  90715 TDAP VACCINE >7 IM 20 1 1.00

Notes notesEligibility :2021-11-09 @ 16:26:14 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Ferrulli, Michael   DOB:10/24/1983 Tel:718-838-4573 SSN:  Sex: M

   Address:7743 75TH ST, RIDGEWOOD, NY 11385-8238
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Ferrulli,Michael  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:UES542W06399   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

GIFFONE, JENNA   DOB:11/20/2012 Tel:347-423-7109 SSN:  Sex: F

   Address:84-06 60 AVE, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:GIFFONE,JENNA  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Emblem Health, PO BOX 3000, NY, NY 10116-3000
    Copay:   Subscriber No:K9053538103   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00

Notes notesEligibility :2021-11-09 @ 16:40:30 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Robelo, Rebecca   DOB:11/08/1996 Tel:646-361-7221 SSN:  Sex: F

   Address:3, 5225 72nd Pl, MASPETH, NY, US 11378
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Robelo,Rebecca  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:D2W740863157   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. S01.332A Complication of left ear piercing, initial encounter (primary)  

2. H92.02 Left ear pain   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 H92.01 20 1 1.00 $172.00

Co-Pay Paid 10.00   Credit Card

notesEligibility :2021-11-09 @ 16:35:06 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 16:35:06
EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 16:35:05 EST : Eligible : Eligible; notesEligibility
Notes
:2021-11-09 @ 16:35:03 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 16:35:03 EST : Eligible :
Eligible;
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

MERCADO, JOSE   DOB:10/14/1992 Tel:917-349-1309 SSN:  Sex: M

   Address:3368 FULTON ST, BROOKLYN, NY 11208
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:MERCADO,JOSE  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99201 Office Visit, New Pt., Level 1 Z20.822 20 1 1.00 $107.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

ALI, ADIL   DOB:03/04/1988 Tel:646-315-3460 SSN:  Sex: M

   Address:7820 32ND, EAST ELMHURST, NY 11370
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:ALI,ADIL  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Healthfirst Inc New York, 25 Broadway 9th Floor, New York, NY 10004
    Copay:   Subscriber No:SG38297W   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Mercado, Edwin   DOB:12/26/1985 Tel:516-262-0126 SSN:105-70-7670  Sex: M

   Address:3368 FULTON ST, BROOKLYN, NY 11208-2034
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Mercado,Edwin  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Ortiz, Edgardo   DOB:08/16/1989 Tel:718-200-2648 SSN:  Sex: M

   Address:6118 68th Ave, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Ortiz,Edgardo  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Montapert, Demetrios   DOB:07/18/1989 Tel:347-256-1165 SSN:  Sex: M

   Address:59-06 Woodbine St, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Montapert,Demetrios  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. HIP, PO BOX 2845, NEW YORK, NY 10116
    Copay:   Subscriber No:K6054864201   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99212 Office Visit, Est Pt., Level 2 Z20.822 20 1 1.00 $105.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 17:23:07 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

FIGUEREO, CLAUDIA B   DOB:11/16/1991 Tel:347-640-9839 SSN:  Sex: F

   Address:6259 FOREST AVE, RIDGEWOOD, NY 11385-2347
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:FIGUEREO,CLAUDIA B 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:JLJ720567838   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. J06.9 Viral upper respiratory infection (primary)  

2. Z20.822 Contact with and (suspected) exposure to covid-19   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 J06.9 Z20.822 20 1 1.00 $172.00
  87426 rapid covid testing Z20.822J06.9 20 1 1.00 $100.00
  87804 INFLUENZA ASSAY W/OPTIC J06.9 Z20.822 20 1 1.00 $50.00

Notes notesEligibility :2021-11-09 @ 17:22:56 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Kowalczuk, Katarzyna   DOB:09/19/1979 Tel:347-320-1666 SSN:  Sex: F

   Address:5918 56TH DR, MASPETH, NY 11378-2315
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Kowalczuk,Katarzyna  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Aetna, PO BOX 14079, LEXINGTON, KY 40512
    Copay:   Subscriber No:w26480651701   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes notesEligibility :2021-11-09 @ 17:23:40 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

DIAZ, MARIA E   DOB:02/21/1963 Tel:917-371-6159 SSN:  Sex: F

   Address:87 HARMAN ST, BROOKLYN, NY 11221-3817
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:DIAZ,MARIA E 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Fidelis Care New York, PO Box 8052, Amherst, NY 14226
    Copay:   Subscriber No:74488281900   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

SUAREZ, MELVIN   DOB:09/04/2001 Tel:917-499-7604 SSN:  Sex: M

   Address:6419 PALMETTO ST, #2, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:SUAREZ,MELVIN  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:ETRBJ0677644   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99201 Office Visit, New Pt., Level 1 Z20.822 20 1 1.00 $107.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 17:22:43 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

CLARKE, KHALILAH   DOB:11/26/1992 Tel:347-513-2475 SSN:  Sex: F

   Address:966E 221 ST, BRONX, NY 10469
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L   
Assigned To : Schenker, Josef D

Responsible Party Name:CLARKE,KHALILAH  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Boller, Alexa   DOB:04/10/2004 Tel:646-296-3301 SSN:  Sex: F

   Address:58-11 66th St, MASPETH, NY, US 11378
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Boller,Deborah  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Cigna, PO Box 188055, Chattanooga, TN 37422
    Copay:0.00   Subscriber No:U4727414704   Group No:

   
Insured's relation to patient:Self - patient is the insured
2. QUALCARE ADMINSTRATORS, PO BOX 219, PISCATAWAY, NJ 08855-0121
    Copay:0.00   Subscriber No:U4727414704   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. J02.9 Acute pharyngitis (primary)  

2. Z20.822 Contact with and (suspected) exposure to covid-19   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 J02.9 Z20.822 20 1 1.00 $172.00
  87880 STREP A ASSAY W/OPTIC J02.9 20 1 1.00 $25.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00
  J1100 INJ DEXETHOSONE SODIM PHOSHATE J02.9 20 1 10.00
$300.00
1 MG
  96372 THER/PROPH/DIAG INJ, SC/IM J02.9 20 1 1.00 $49.00

notesEligibility :2021-11-09 @ 17:34:07 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 17:34:05

Notes
EST : Eligible : InEligible;
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Velez, Zulmarie   DOB:12/31/1982 Tel:347-906-0761 SSN:  Sex: F

   Address:6607 74TH ST, FL 1, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L   
Assigned To : Schenker, Josef D

Responsible Party Name:Velez,Zulmarie  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Emblem Health, PO BOX 3000, NY, NY 10116-3000
    Copay:   Subscriber No:K6040204501   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

notesEligibility :2021-11-09 @ 17:34:52 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 17:34:51

Notes
EST : Eligible : Eligible;
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

ORTIZ, JESSICA L   DOB:01/23/1995 Tel:929-841-2663 SSN:  Sex: F

   Address:6011 COOPER AVE, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:ORTIZ,JESSICA L 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:JLJ725876442   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. S81.811A Laceration of right lower leg, initial encounter (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99203 Office Visit, New Pt., Level 3 S81.811A 20 1 1.00 $258.00

Notes notesEligibility :2021-11-09 @ 17:42:48 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

SALCEDO, Carolina   DOB:11/20/1976 Tel:347-631-1861 SSN:129-60-7474  Sex: F

   Address:5854 79TH AVE, RIDGEWOOD, NY, US 11385-6027
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:SALCEDO,Carolina  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Aetna, PO BOX 14079, LEXINGTON, KY 40512
    Copay:   Subscriber No:W256456184   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  36415 VENIPUNCT, ROUTINE* Z20.822 20 1 1.00 $30.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 18:38:21 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

RESPASS, MALCOLM X   DOB:10/12/1971 Tel:347-280-4087 SSN:  Sex: M

   Address:11 MIDWOOD ST, BROOKLYN, NY 11225
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:RESPASS,MALCOLM X 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:JLJ006633484   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

GECSEDI, RICHARD P   DOB:02/01/1989 Tel:718-536-4538 SSN:  Sex: M

   Address:120 LAWSON AVE, EAST ROCKAWAY, NY 11518
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:GECSEDI,RICHARD P 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. OXFORD, PO BOX 29130, HOT SPRINGS, AR 71903-9041
    Copay:   Subscriber No:19445775600   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  36415 VENIPUNCT, ROUTINE* Z20.822 20 1 1.00 $30.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00
  87804 INFLUENZA ASSAY W/OPTIC Z20.822 20 1 1.00 $50.00

Notes notesEligibility :2021-11-09 @ 18:25:16 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

RODRIGUEZ, JOSE A   DOB:10/22/1985 Tel:347-430-8107 SSN:  Sex: M

   Address:2029 GREENE AVE, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:RODRIGUEZ,JOSE A 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:ETRBJ0833391   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 19:00:31 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

RODRIGUEZ, JEREMY J   DOB:09/30/2010 Tel:347-430-8107 SSN:  Sex: M

   Address:2029 GREENE AVE, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:RODRIGUEZ,JEREMY J 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:ETRBJ0833391   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 18:25:09 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Muffoletto, Jerome   DOB:07/15/1953 Tel:646-932-4061 SSN:  Sex: M

   Address:62-32 60DR, MASPETH, NY, US 11378
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Muffoletto,Jerome  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Medicare, PO Box 4751, Syracuse, NY 13221
    Copay:   Subscriber No:6HF8M94WV59   Group No:

   
Insured's relation to patient:Self - patient is the insured
2. Emblem Health, PO BOX 3000, NY, NY 10116-3000
    Copay:   Subscriber No:K9055843101   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z23 Encounter for immunization   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00
  91301 COVID 19 Vaccination Z20.822 20 80 1.00
  0003a PFIZER Dose #3 Z20.822 20 80 1.00
   COVID- 19 PFIZER 1.00

notesEligibility :2021-11-09 @ 18:25:04 EST : Eligible : Eligible; notesEligibility :2021-11-09 @ 18:24:57

Notes
EST : Eligible : Eligible;
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

FERRARA MUFFOLETTO, ANGELA   DOB:06/11/1952 Tel:646-932-4061 SSN:  Sex: F

   Address:6232 60TH DR, MASPETH, NY 11378
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:FERRARA MUFFOLETTO,ANGELA  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Medicare, PO Box 4751, Syracuse, NY 13221
    Copay:   Subscriber No:6GW4C24PW92   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 18:37:59 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Bracic, Sofia   DOB:03/20/2013 Tel:718-316-8303 SSN:  Sex: F

   Address:1928 GROVE ST, 1r, RIDGEWOOD, NY, US 11385-2342
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Bracic,Sadija  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. MagnaCare, PO BOX 1001, GARDEN CITY, NY 11530
    Copay:50.00   Subscriber No:RWD552499   Group No:

   
Insured's Name:Bracic,Sadija    
Insured's relation to patient:Natural Child - Insured has Financial Responsibility
    Insured's Address:1928 GROVE ST, RIDGEWOOD, NY 11385-2342

ICD-9 Codes 1. H61.23 Excessive cerumen in both ear canals (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99213 Office Visit, Est Pt., Level 3 H92.02 20 1 1.00 $172.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

LORA, JANELLE   DOB:12/12/1991 Tel:347-575-4427 SSN:  Sex: F

   Address:558 GRANDVIEW AVE, RIDGEWOOD, NY 11385-1956
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:LORA,JANELLE  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Cigna, PO Box 188055, Chattanooga, TN 37422
    Copay:   Subscriber No:U66757020   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 18:25:37 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

PAASCH, LEO   DOB:12/10/2006 Tel:347-342-8643 SSN:  Sex: M

   Address:370A GRAND AVE, 2F, BROOKLYN, NY 11238
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:PAASCH,LEO  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:BFXAN6636970   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 18:37:52 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

DIAZ, NICHOLAS   DOB:05/01/2001 Tel:917-423-5988 SSN:  Sex: M

   Address:132 LIPTON LN, WILLISTON PARK, NY 11596
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:DIAZ,NICHOLAS  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Fidelis Care New York, PO Box 8052, Amherst, NY 14226
    Copay:   Subscriber No:74437598200   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z23 Encounter for immunization   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  91300 PFIZER VACCINE Z20.822 20 80 1.00
  0001A ADM SARSCOV2 30MCG/0.3ML 1ST Z20.822 20 1.00
   COVID- 19 PFIZER Z20.822 1.00

Notes notesEligibility :2021-11-09 @ 19:00:02 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

KOZIEL, ALEKSANDER   DOB:06/01/2006 Tel:347-527-3348 SSN:  Sex: M

   Address:6149 ELIOT AVE, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:KOZIEL,ALEKSANDER  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:JLJ006488720   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z23 Encounter for immunization   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  91301 COVID 19 Vaccination Z20.822 20 80 1.00
  0002A PFIZER dose 2 Z20.822 20 80 1.00
   COVID- 19 PFIZER 1.00

Notes notesEligibility :2021-11-09 @ 19:00:19 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Abdelkarim, Mohmed   DOB:12/01/1996 Tel:646-744-7217 SSN:  Sex: M

   Address:6128 LINDEN ST, RIDGEWOOD, NY 11385-3323
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Abdelkarim,Mohmed  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. UNITED HEALTH CARE, PO BOX 740800, ATLANTA, GA 30374-0484
    Copay:   Subscriber No:46499926602   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 18:59:51 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

KOSTIC, IVICA   DOB:09/23/1983 Tel:646-363-7805 SSN:  Sex: M

   Address:7238 CALDWELL AVE, MASPETH, NY 11378-2619
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:KOSTIC,IVICA  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

SATWIN RAMBERG, MARTA   DOB:06/21/1975 Tel:646-641-8564 SSN:  Sex: F

   Address:6030 67TH AVE, RIDGEWOOD, NY 11385-4536
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:SATWIN RAMBERG,MARTA  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. UNITED HEALTH CARE, PO BOX 740800, ATLANTA, GA 30374-0484
    Copay:   Subscriber No:925165125   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

LOPEZ, BYRON G   DOB:08/15/1959 Tel:718-506-2021 SSN:  Sex: M

   Address:8968 COOPER AVE, REGO PARK, NY 11374-5324
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:LOPEZ,BYRON G 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:NYB605W02533   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 19:08:49 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

LOPEZ, GRACE E   DOB:12/19/1958 Tel:718-506-2021 SSN:  Sex: F

   Address:8968 COOPER AVE, REGO PARK, NY 11374-5324
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:LOPEZ,GRACE E 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:NYB605W02533   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 19:08:42 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

LOPEZ, BRYANT G   DOB:06/11/1993 Tel:347-804-8308 SSN:  Sex: M

   Address:8968 COOPER AVE, REGO PARK, NY 11374
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:LOPEZ,BRYANT G 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:JLJ727956396   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99201 Office Visit, New Pt., Level 1 Z20.822 20 1 1.00 $107.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 19:08:34 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Simonelli, Chelsea M   DOB:02/25/1993 Tel:917-680-9234 SSN:  Sex: F

   Address:1732 MENAHAN ST, RIDGEWOOD, NY 11385-2129
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Simonelli,Chelsea M  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. BCBS Health Plus, PO BOX 61010, VIRGINIA BEACH, VA 23466-1010
    Copay:   Subscriber No:JLJ006781119   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99212 Office Visit, Est Pt., Level 2 Z20.822 20 1 1.00 $105.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 19:22:46 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Simonelli, Damaris   DOB:01/27/1968 Tel:718-807-4621 SSN:  Sex: F

   Address:1732 MENAHAN ST, RIDGEWOOD, NY 11385-2129
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Simonelli,Damaris  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. VNS CHOICE MEDICARE, po box 4498, scranton, PA 18505
    Copay:   Subscriber No:V80042217   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99212 Office Visit, Est Pt., Level 2 Z20.822 20 1 1.00 $105.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

BHARATH, ELAINE   DOB:11/29/1972 Tel:347-706-9399 SSN:  Sex: F

   Address:7737 FURMANVILLE, 2, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:BHARATH,ELAINE  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Healthfirst Inc New York, 25 Broadway 9th Floor, New York, NY 10004
    Copay:   Subscriber No:MM56855Y   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99201 Office Visit, New Pt., Level 1 Z20.822 20 1 1.00 $107.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 19:29:12 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

GALLO, FRANCIS A   DOB:01/08/1975 Tel:718-757-6970 SSN:  Sex: M

   Address:6326 76TH ST, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:GALLO,FRANCIS A 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Emblem Health, PO BOX 3000, NY, NY 10116-3000
    Copay:   Subscriber No:K9054490202   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. R50.9 Fever, unspecified fever cause (primary)  

2. B34.9 Viral syndrome   
3. Z20.822 Contact with and (suspected) exposure to covid-19   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99203 Office Visit, New Pt., Level 3 Z20.822R50.9 B34.9 20 1 1.00 $258.00
  87880 STREP A ASSAY W/OPTIC R50.9 B34.9 20 1 1.00 $25.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00
  87804 INFLUENZA ASSAY W/OPTIC R50.9 B34.9 20 1 1.00 $50.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Korczynski, Dawid   DOB:01/20/1985 Tel:347-429-1421 SSN:  Sex: M

   Address:6157 71ST ST, MIDDLE VILLAGE, NY 11379-1231
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Korczynski,Dawid  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Narvaez, Claudia   DOB:04/04/1969 Tel:347-498-5180 SSN:  Sex: F

   Address:197 Shepherd Ave, BROOKLYN, NY 11208
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Narvaez,Claudia  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. MetroPlus Health Plan, PO Box 1966, New York, NY 10116
    Copay:   Subscriber No:XM56906T   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes notesEligibility :2021-11-09 @ 19:55:29 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

SUAREZ, EMILY ROSE   DOB:08/28/1995 Tel:929-339-2839 SSN:  Sex: F

   Address:197 SHEPHERD AVE, BROOKLYN, NY 11208
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:SUAREZ,EMILY ROSE  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

KOTWICA, PAWEL   DOB:06/14/1988 Tel:332-202-5717 SSN:  Sex: M

   Address:6010 FRESH POND RD, MASPETH, NY 11378-3454
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:KOTWICA,PAWEL  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

MACIEJEWSKI, SEBASTIAN T   DOB:03/07/1976 Tel:646-546-4296 SSN:  Sex: M

   Address:603 CLOUD CREST, WHITE MILLS, PA 18473
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:MACIEJEWSKI,SEBASTIAN T 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Blue Cross and Blue Shield of New York E, PO Box 1407, New York, NY 10008
    Copay:   Subscriber No:YXE714M99029   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes notesEligibility :2021-11-09 @ 19:45:49 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

PLOSZAJ, SEBASTIAN   DOB:05/14/1991 Tel:646-724-1400 SSN:  Sex: M

   Address:7320 69TH AVE, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:PLOSZAJ,SEBASTIAN  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

Mateas, Mariana   DOB:03/17/1964 Tel:315-921-2941 SSN:  Sex: F

   Address:6071 71st Ave, RIDGEWOOD, NY 11385
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:Mateas,Mariana  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Emblem Health, PO BOX 3000, NY, NY 10116-3000
    Copay:   Subscriber No:k1016429401   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

2. Z20.828 Close exposure to 2019 novel coronavirus   

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822Z20.828 20 1 1.00 $51.00

Notes notesEligibility :2021-11-09 @ 19:43:00 EST : Eligible : Eligible;

 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

IORIO, CHRISTINE M   DOB:03/12/1968 Tel:718-637-7937 SSN:  Sex: F

   Address:8339 60TH DR, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:IORIO,CHRISTINE M 

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Aetna, PO BOX 14079, LEXINGTON, KY 40512
    Copay:   Subscriber No:W231587008   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00
  S9083 GLOBAL FEE URGENT CARE CENTERS Z20.822 20 1 1.00 $180.00

Notes
 Churchill,Alexandra L

Tel: Fax:

Billing Data Tuesday, November 9, 2021

IORIO, LOUIS   DOB:08/22/1999 Tel:347-853-3305 SSN:  Sex: M

   Address:8339 60TH DR, Middle Village, NY 11379
   Employer :Tel:
   
Service Date : 11/09/2021   
Resource Name : Churchill,Alexandra L

Responsible Party Name:IORIO,LOUIS  

Provider No:
Group No:
Tax Id:  
NPI:
Facility : Centers Urgent Care Queens

Insurance(s) :
1. Aetna, PO BOX 14079, LEXINGTON, KY 40512
    Copay:   Subscriber No:W231587008   Group No:

   
Insured's relation to patient:Self - patient is the insured

ICD-9 Codes 1. Z20.822 Contact with and (suspected) exposure to covid-19 (primary)  

Billed
Procedure Codes Modifiers ICD1 ICD2 ICD3 ICD4 POS TOS Units
Fee
  99211 Office Visit, Est Pt., Level 1 Z20.822 20 1 1.00 $51.00
  87426 rapid covid testing Z20.822 20 1 1.00 $100.00

Notes