Katherine Marsh
HAL-1047via Priya Anand, DPT, CLT · Central Texas Lymphatic Therapy
Intake
Submitted Dec 12, 12:00 AM
Patient Info
- Full name
- Katherine Marsh
- DOB
- 03/08/1963
- k.marsh@example-mail.test
- Phone
- (512) 555-0104
- Shipping address
- 5501 Balcones Dr Ste 210, Austin, TX 78731
Health Coverage
INSURED
- Payer
- BCBS Texas
- Plan
- PPO
- Coverage %
- 90%
- Member ID
- TXP-7781204
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$70.20
Patient$7.80
Line total$78.00
Juzo Basic Gauntlet
Juzo · HCPCS A6549 · Cost $13.00
Product
Juzo Basic Gauntlet
Juzo · HCPCS A6549
Qty2
Payer$41.40
Patient$4.60
Line total$46.00
Calculation
- Payer coverage
- $111.60
- Patient responsibility
- $12.40
- Order total
- $124.00
Product cost(s) $72.00 · Margin $52.00 (41.9%)
Consent and Payment
Paid — Dec 13, 12:00 AM
Ready for Vendor
Packet sent Dec 14, 12:00 AM
Placed with Vendor
Placed Dec 14, 12:00 AM
Delivered
Delivered Dec 19, 12:00 AM
Completed
POD signed Dec 20, 12:00 AM
Order closed. The page above reads top-to-bottom as this order's full history.
Activity Log
- Dec 12, 12:00 AMDraft submitted
- Dec 12, 12:01 AMEncounter form generated
- Dec 13, 12:00 AMPayment recorded
- Dec 14, 12:00 AMPlaced with Juzo — order #JZ-70821
- Dec 19, 12:00 AMDelivered by Juzo
- Dec 19, 12:00 AMPOD generated
- Dec 20, 12:00 AMPOD signed