Use the following information to complete this health insurance claim form. Use the Internet to find the correct medical coding for this diagnosis and determine realistic charges for these services.
A male patient named Robert Blake first went to his doctor, Roy Blanchard, at Better Medical Clinic on January 10, 2015 for an office visit. Robert had a unilateral chest X-ray, which revealed a broken rib due to a car accident on January 8, 2015. There was a follow-up office visit on March 15, 2015. Robert lives at 2400 East Highland Drive, Boland, MN 84672. His phone number is (840) 672-3456. His wife, Shelly, drove him to the clinic. She does not work outside the home. Robert is insured with a signature on file through the Benefit Health Plan, group number 02635. The insurer’s I.D. number is 04635. Robert was born November 11, 1984. The patient account number is 0429 with an accepted assignment federal tax I.D. number 38-0000.000. The billing provider’s phone number is (426) 814-7639. Robert did not pay for any services yet.