Derek Solano
HAL-1048via Dana Whitfield, PT, DPT, CLT · Austin Lymphedema & Rehab
Intake
Submitted Dec 23, 12:00 AM
Patient Info
- Full name
- Derek Solano
- DOB
- 05/19/1972
- d.solano@example-mail.test
- Phone
- (512) 555-0211
- Shipping address
- 1204 Barton Springs Rd, Austin, TX 78704
Health Coverage
INSURED
- Payer
- Aetna
- Plan
- Choice POS II
- Coverage %
- 80%
- Member ID
- AET-7734021
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$62.40
Patient$15.60
Line total$78.00
Calculation
- Payer coverage
- $62.40
- Patient responsibility
- $15.60
- Order total
- $78.00
Product cost(s) $46.00 · Margin $32.00 (41.0%)
Consent and Payment
Paid — Dec 23, 1:03 AM
Ready for Vendor
Packet sent Dec 26, 12:00 AM
Placed with Vendor
Placed Dec 26, 12:00 AM
Delivered
Delivered Dec 30, 12:00 AM
Completed
POD signed Dec 31, 12:00 AM
Order closed. The page above reads top-to-bottom as this order's full history.
Activity Log
- Dec 23, 12:00 AMDraft submitted
- Dec 23, 12:01 AMEncounter form generated
- Dec 23, 1:03 AMPayment recorded
- Dec 26, 12:00 AMPlaced with vendor
- Dec 30, 12:00 AMDelivered
- Dec 30, 12:00 AMPOD generated
- Dec 31, 12:00 AMPOD signed