Ana Villalba
HAL-1044via Sam Okafor, PT, DPT · Lone Star Breast Health Rehab
Intake
Submitted Dec 30, 10:00 PM
Patient Info
- Full name
- Ana Villalba
- DOB
- 06/23/1959
- a.villalba@example-mail.test
- Phone
- (214) 555-0117
- Shipping address
- 2210 Greenville Ave, Dallas, TX 75206
Health Coverage
INSURED
- Payer
- Medicare
- Plan
- Original Medicare Part B
- Coverage %
- 100%
- Member ID
- 1EG4-TE5-MK72
Product Details
ProductQtyPayerPatientLine total
JOBST Bella Lite Gauntlet, 20–30 mmHg
JOBST · HCPCS A6549 · Cost $27.00
Product
JOBST Bella Lite Gauntlet, 20–30 mmHg
JOBST · HCPCS A6549
Qty1
Payer$46.00
Patient$0.00
Line total$46.00
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$78.00
Patient$0.00
Line total$78.00
Calculation
- Payer coverage
- $124.00
- Patient responsibility
- $0.00
- Order total
- $124.00
Product cost(s) $73.00 · Margin $51.00 (41.1%)
Consent and Payment
Signed — Dec 30, 10:02 PM
Ready for Vendor
- Product
- JOBST Bella Lite Gauntlet, 20–30 mmHg
- Vendor
- JOBST
- Order via
- Product
- Juzo Dynamic Arm Sleeve, 20–30 mmHg
- Vendor
- Juzo
- Order via
Placed with Vendor
Delivered
Completed
Activity Log
- Dec 30, 10:00 PMDraft submitted
- Dec 30, 10:01 PMEncounter form generated
- Dec 30, 10:02 PMConsent signed — nothing owed