Simran Kaur
HAL-1046via Marcus Ilford, PT, CLT · Hill Country Cancer Rehab
Intake
Submitted Dec 24, 12:00 AM
Patient Info
- Full name
- Simran Kaur
- DOB
- 09/14/1990
- s.kaur@example-mail.test
- Phone
- (512) 555-0175
- Shipping address
- 88 Guadalupe St Unit 4B, San Marcos, TX 78666
Health Coverage
INSURED
- Payer
- Aetna
- Plan
- Choice POS II
- Coverage %
- 80%
- Member ID
- AET-6620093
Product Details
ProductQtyPayerPatientLine total
Juzo Basic Gauntlet
Juzo · HCPCS A6549 · Cost $13.00
Product
Juzo Basic Gauntlet
Juzo · HCPCS A6549
Qty1
Payer$18.40
Patient$4.60
Line total$23.00
Calculation
- Payer coverage
- $18.40
- Patient responsibility
- $4.60
- Order total
- $23.00
Product cost(s) $13.00 · Margin $10.00 (43.5%)
Consent and Payment
Paid — Dec 25, 12:00 AM
Ready for Vendor
Packet sent Dec 26, 12:00 AM
Placed with Vendor
Placed Dec 26, 12:00 AM
- Product
- Juzo Basic Gauntlet · Juzo
- Vendor order #
- JZ-88213
Delivered
Completed
Activity Log
- Dec 24, 12:00 AMDraft submitted
- Dec 24, 12:01 AMEncounter form generated
- Dec 25, 12:00 AMPayment recorded
- Dec 26, 12:00 AMPlaced with Juzo — order #JZ-88213