Thomas Bergstrom
HAL-1043OVERDUEvia Priya Anand, DPT, CLT · Central Texas Lymphatic Therapy
Intake
Submitted Dec 29, 12:00 AM
Patient Info
- Full name
- Thomas Bergstrom
- DOB
- 11/02/1975
- t.bergstrom@example-mail.test
- Phone
- (512) 555-0192
- Shipping address
- 740 Cypress Creek Rd, Cedar Park, TX 78613
Health Coverage
SELF-PAY
Product Details
ProductQtyPayerPatientLine total
Juzo Dynamic Arm Sleeve, 20–30 mmHg
Juzo · HCPCS A6549 · Cost $46.00
Product
Juzo Dynamic Arm Sleeve, 20–30 mmHg
Juzo · HCPCS A6549
Qty1
Payer—
Patient$92.95
Line total$92.95
Calculation
- Patient responsibility
- $92.95
- Order total
- $92.95
Product cost(s) $46.00 · Margin $46.95 (50.5%)
Consent and Payment
- Sent
- Dec 29, 1969
- Due
- Jan 5, 1970 · past due
- Patient owes
- $92.95
Awaiting Payment
Awaiting Signature
Prototype control
Demo stand-in for two separate webhooks (DocuSign consent + Stripe payment). In the real system the patient's own actions fire these.
Ready for Vendor
Placed with Vendor
Delivered
Completed
Activity Log
- Dec 29, 12:00 AMDraft submitted
- Dec 29, 12:01 AMEncounter form generated