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<br />08/18/2008
<br />
<br />949-8302324
<br />
<br />10:34
<br />
<br />Det1l1is A. Colucci, Au.D., MA., FAAA
<br />
<br />AudltOty Di$Dtders lIl1C' BafClnce J,..abaratory
<br />Soard C.rtJfted In AudiolOgy
<br />
<br />23981 Calle De La Magdalena, Suite 355
<br />Laguna Hills, Ca 92853
<br />949 830-5710 949 830-2324 FAX
<br />Licenses Au 348 { HA 1028
<br />
<br />PAGE
<br />
<br />03
<br />
<br />DENNIS COLUCCI MA
<br />
<br />Patient:
<br />
<br />Date:
<br />
<br />21~.OO
<br />
<br />~~()O()
<br />30"00
<br />
<br />l:;O:m
<br />20S.~1l
<br />
<br />'24(l.~C1
<br />
<br />;240,00
<br />
<br />150.00
<br />120,00
<br />11-0,00
<br />.1~O 00
<br />160.00
<br />90.00
<br />25('1,00
<br />
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<br />
<br />22~ J
<br />336.01
<br />3S$.4j
<br />~!JQ.Jl
<br />3$9,14
<br />3&';1,0
<br />&72.8
<br />V721J
<br />-'11.lff
<br />nS.41
<br />JIO.~
<br />JI!;I,~
<br />3$5."4
<br />J$)I,12
<br />~t8.'O
<br />:180.1
<br />38:2.9
<br />387.2
<br />3084.2
<br />319.11
<br />~IW.16
<br />3$9.1~
<br />389.1B
<br />389.10
<br />3M1.31
<br />J88.n
<br />:I.BB.l
<br />~O.<1
<br />386.2
<br />\172:.19
<br />
<br />A((1Ll9tIc. ~eu~Otm
<br />AC1in M~iere'$ Di~9$t!
<br />Auditory DiW'im:lzticlIl O...fel;it. lmo&irnd Di~trimin:stiGI1
<br />appv
<br />c.r'ttral1i*El"'llk LOll~. 61lttml
<br />(;(I~{luo::llV$~(ln8I..ou
<br />e.rTrll.lfl\'
<br />Br.cQI,InterFJ.l1edScrcenirl,ll.
<br />E~21adli:&n Th;e Dv~fundion
<br />H"o.erACll~i,
<br />tmp.JcteclC;erumel'l
<br />M;~lId lmlril$.l.oS!
<br />M~nilll1l'B Diseue Il'lIOCti~
<br />NOlm.l KmriI\A Lo~. Di\:l!oml.1
<br />Otahr:illo
<br />Otit)~E'tttrnt
<br />Otl11sMCldll
<br />O(()S.~!~OS;'
<br />1>crl'ort101dryrt'll)'lli(.M~mbrltt'le
<br />SenIQrvf.:lct.rir->tl-Q$S,$ilQ1Ql'il
<br />Slm~ClrinCUTlll. Hcaril1lli LCI~ UnileJMI.l
<br />Son~~nounlllinri"1l; l.o~s, AsvmTDOtl'ic;al
<br />StnP>rlrlneurel HiM.-::nl! LOOI~ Combined. Bi]c~ellll
<br />Stll~1"\' Hearll\j:l 1.0&3 -U~spccifiod
<br />Tiflnltui,SubJrilC'li~
<br />Tinnllu~, ObJa!tI'ie
<br />g\.(ldtrlSil:tl9(M'iJ\i;W'llJf'w.riIl~L~
<br />Di:..zineJS.Gi.:ldinus.Ll.llht"Hca.ded~
<br />VtrotiltO.Olllll'llIOril:ill
<br />Ot~C! ExAmln.tlQIl (lor~~rf Al'I(I A'i:Qri~B
<br />
<br />SSN:
<br />
<br />008:
<br />
<br />Physician
<br />
<br />M.D. UPIN:
<br />
<br />Lie.
<br />
<br />
<br />0 n~,7 Comprelll,"~iv" f'll'llri"1l. e:valu~lQf)
<br />0 nS52 AlrC()l'od...<<>(tnT~
<br />0 onm A.irlndBolll!Car.du-.tionTIl!lU
<br />" 92361 ABLB, L.ouc!!\m' JhIMl;~
<br />" 9'25~~ TIlIlt Oll;l:~~ ,~;
<br />" 92555 SlO1l\Btf,P\lI'll'f'O".e.
<br />" 512H7 Speeah$l~
<br />D 92561 "TymplUlOlnctl')' S9ClI SJ:25
<br />0 92S68- Acou~i,,'R(lre:'<<ls
<br />0 92569 Ac.oU:5tI"P.o~01tD~"
<br />0 92584 E]ClCtr\XOc;~IOO8t'.P")'
<br />C 92583- OlA!l1Q~ll" OI~()I'li~ PrQd. Otocmustic; E.miS5ions
<br />0 51;l5!:l AB2P rComp:ex) s:J50/~SSO
<br />" 92,.., 'I'irtulaTaji
<br />" 92:141 SPOmMCoQIl; Ny;tllBr.v..t~ 1'1!:$l.s
<br />" 92~ Positil:llll! Nyl'tISJ'!Il1~Te;:,(6xS40.00}
<br />" "'" Bithermd CIIQri~ (4x $60.00)
<br />:J "'" (~WftII:l"Odoric.s(2lc:~go,OO)
<br />D .',., Op1<)ldn~lc'r~3(4K)O,M)
<br />" 92545 05cilll.ting Tl'WOking T~SI~
<br />" ,.",. Sim~idal V~rtiCll!llioti7,(lnlal Allie 1t.o!Mio", Ttets
<br />" 'jI2S47 SUppI4l1'1.eI\IQIEftClrl:l(lt1'<<l(Vel1~X'$40,C:o)
<br />D 92700 A~ndinli-~d;ll!! OQpe....a1u.tinn
<br />q 92:700 PC$UIl:?lllfonr.'EVIIlllf..lion
<br />
<br />
<br />4~.OO
<br />
<br />r;J 92582
<br />C ns~3
<br />
<br />90.00
<br />
<br />C 92(i2O
<br />C 92al
<br />
<br />4Hl'
<br />
<br />45,00
<br />
<br />4500
<br />~~.OO
<br />
<br />o 9~@;i
<br />o 92627
<br />
<br />o 92519
<br />
<br />j5.oo
<br />
<br />CJ 92~'16
<br />(J 92625
<br />
<br />3~.QO
<br />
<br />o 92100
<br />o ml0
<br />o 9l}443
<br />
<br />P 91700
<br />o 92700
<br />o 92590
<br />
<br />o oml
<br />
<br />o 91$92
<br />o 9m3
<br />
<br />o 92594
<br />o n59S
<br />
<br />::J V501!
<br />
<br />:;I VSOII
<br />
<br />
<br />o Y5:yj4
<br />
<br />C<l~Play A'Jdiom~
<br />
<br />30,00
<br />
<br />:p1Cl,l,II'l:Sel~ionTM1
<br />
<br />80.00
<br />
<br />Cent1'ftl A.uditl:lry'P~ins e.valuatim. Fn'~ Hwr
<br />
<br />HO.OO
<br />
<br />Ctmral Aw:llull'Y l'r~ing 'EVil!. Num::'M" of Uniu
<br />
<br />F.vA1UIltiOll of Auditory Roh$b,!i~tJo)n SUU'J!. rim l40ur
<br />
<br />)51;\.00
<br />
<br />E~h.:.a(lQn of A.udilory Reh&bililltiQn StlUe9, NUtl'Iber (lf1Jn,ll$
<br />
<br />YiMIl ~$Inf(lr~tnl AudiC)tllctry
<br />
<br />IH.on
<br />
<br />Ear PTot.c~liOIl Attt'll'lulll('ll' MU~Ll(rea
<br />
<br />90.00
<br />
<br />Aneume:rrl ofTjnrtit~~
<br />
<br />1;2~.OO
<br />
<br />RurilllJ in NoiH Teat (HTNT)
<br />(:IT\Jfllen Man.;semllnt JITo.;:edul'll s~s I $55
<br />
<br />225.00
<br />
<br />c.:mNhl~i()n, !b:, aum, Dl!:tli~o", CaJ.ctJllIlioM
<br />
<br />FO~$iC~ytJuat!Q"I)IU1JlIPOrt
<br />D1lpo,itiOC!(lr'Cour1Apl.learenee
<br />Hearing Aid ~]n;tion Ewlllar:iOl:\, MOlliural
<br />
<br />\75.00
<br />
<br />HwI~ Aid selection eyalulclon. alr1m....1
<br />
<br />350.00
<br />
<br />allllnns Aid Confi:mnity EVllh:.WQn. MDllBUI'!II
<br />
<br />4COOO
<br />
<br />Htulna:AidCoDfur/YtltyBVQIuatIOll,13I(tII,L.'l.1
<br />
<br />gCiOOu
<br />
<br />E1k1ro-Al:lOLl.G1ie or Prob(! Mle. TCSlin$. M():r$llral
<br />
<br />~Q,OO
<br />
<br />EIO!Ctro.AooLl..'Itic orPn:Jbe Mil:. TMting, Sinlural
<br />
<br />180,00
<br />
<br />HflnIl8,1l.ltlC1Q.1111lgMOIlI1,lrtl
<br />
<br />$4"!$~~I$6~!S7:'
<br />
<br />HClnllg Aid ClRni,,!! Bin=l
<br />
<br />S90Ii;10/S130/SI50
<br />
<br />EllfITIold MofltlJral or e.h\9:Uft\!
<br />
<br />SI:;!S IS2~O
<br />
<br />o V$:IO Di!;p~ingF~ ~OI:l{)C1/4COIS[}CI~OO
<br />:J 9m2 Li:nitedOffi.:.cVisil
<br />
<br />75.00
<br />
<br />o 9~13 Limited Pol[ow..UpOreceViail
<br />
<br />"'~.co
<br />
<br />o VW104 In.l-lOO4,,,,~lt $2Sf $3SI $4$f SS~ilS1OO
<br />
<br />D V50]4 Fatmn'Rlllpllir 52001 $250' S300 1S3~OI400
<br />o V5266 Batlerie~ lC 3t2 13 (,75
<br />
<br />D 9900:2 PrMIJe1. OilPt.nstll~
<br />o VS090 Oi;peruing
<br />D YS257 HMtil'llj: Aid Ate=lary
<br />C V,5275 Impre:l$iQ~ Mq"l/.Ul"llllBln~\lrftl $'00/$:<00
<br />
<br />D
<br />
<br />D 92700
<br />
<br />CHARGES
<br />
<br />AMOUNT PAlO
<br />
<br />BALANCE DUE
<br />
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