Corporate Health Management
7515 Greenville Avenue, Suite 605
Dallas, Texas 75231

(214) 361-0995
(214) 361-0865 FAX
Tax ID #: 75-2430306

Please fill out the following form and it will be emailed to you.
Name of Patient:	Date of Procedure:
DOB:	SS#
Physician: J. Paul Sanders, M.D.	$ Amount Paid:
Your Email Address:
Vaccine(s) ICD-9 Code CPT Code Hepatitis A V05.3 90633 Hepatitis B V05.3 90746 Tetanus/Diphtheria/Pertussis V06.1 90715 Influenza V04.81 90658 Tetanus/Diphtheria V06.50 90718 Pneumovax V03.83 90732 Zostavax V04.89 90736 Note: The vaccine(s) marked above have been paid in full for by the patient stated above.         PLEASE SEND REIMBURSEMENT CHECK TO THE ADDRESS BELOW: