Maya Okonkwo
HAL-1042via Marcus Ilford, PT, CLT · Hill Country Cancer Rehab
Intake
Submitted Dec 31, 7:00 PM
Patient Info
- Full name
- Maya Okonkwo
- DOB
- 04/11/1968
- m.okonkwo@example-mail.test
- Phone
- (512) 555-0148
- Shipping address
- 915 Ranch Rd 620 N, Round Rock, TX 78681
Health Coverage
INSURED
- Payer
- Medicare
- Plan
- Original Medicare Part B
- Coverage %
- 100%
- Member ID
- 4KM2-TE9-WL61
Product Details
ProductQtyPayerPatientLine total
Juzo Compression Wrap Calf
Juzo · HCPCS A6531 · Cost $58.00
Attached: okonkwo-calf-measurements.pdf
Product
Juzo Compression Wrap Calf
Juzo · HCPCS A6531
Attached: okonkwo-calf-measurements.pdf
Qty1
Payer$95.00
Patient$0.00
Line total$95.00
Calculation
- Payer coverage
- $95.00
- Patient responsibility
- $0.00
- Order total
- $95.00
Product cost(s) $58.00 · Margin $37.00 (38.9%)
Pending Approval
Juzo Compression Wrap Calf
HCPCS A6531
Consent and Payment
Ready for Vendor
Placed with Vendor
Delivered
Completed
Activity Log
- Dec 31, 7:00 PMDraft submitted