Rachel Adeyemi
HAL-1045OVERDUEvia Dana Whitfield, PT, DPT, CLT · Austin Lymphedema & Rehab
Intake
Submitted Dec 20, 12:00 AM
Patient Info
- Full name
- Rachel Adeyemi
- DOB
- 01/30/1981
- r.adeyemi@example-mail.test
- Phone
- (512) 555-0163
- Shipping address
- 3300 Duval St Apt 12, Austin, TX 78705
Health Coverage
INSURED
- Payer
- UnitedHealthcare
- Plan
- Choice Plus
- Coverage %
- 70%
- Member ID
- UHC-88231145
Product Details
ProductQtyPayerPatientLine total
JOBST Bella Lite Arm Sleeve, 20–30 mmHg
JOBST · HCPCS A6549 · Cost $34.00
Product
JOBST Bella Lite Arm Sleeve, 20–30 mmHg
JOBST · HCPCS A6549
Qty2
Payer$81.20
Patient$34.80
Line total$116.00
Calculation
- Payer coverage
- $81.20
- Patient responsibility
- $34.80
- Order total
- $116.00
Product cost(s) $68.00 · Margin $48.00 (41.4%)
Consent and Payment
- Sent
- Dec 20, 1969
- Due
- Dec 30, 1969 · past due
- Patient owes
- $34.80
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 20, 12:00 AMDraft submitted
- Dec 20, 12:01 AMEncounter form generated