Wanda Ferris
HAL-1049via Marcus Ilford, PT, CLT · Hill Country Cancer Rehab
Intake
Submitted Dec 22, 12:00 AM
Patient Info
- Full name
- Wanda Ferris
- DOB
- 08/02/1965
- w.ferris@example-mail.test
- Phone
- (214) 555-0138
- Shipping address
- 2210 Greenville Ave, Dallas, TX 75206
Health Coverage
INSURED
- Payer
- UnitedHealthcare
- Plan
- Choice Plus
- Coverage %
- 70%
- Member ID
- UHC-55021837
Product Details
ProductQtyPayerPatientLine total
JOBST Bella Strong Arm Sleeve, 20–30 mmHg
JOBST · HCPCS A6531 · Cost $35.00
Product
JOBST Bella Strong Arm Sleeve, 20–30 mmHg
JOBST · HCPCS A6531
Qty1
Payer$41.30
Patient$17.70
Line total$59.00
Calculation
- Payer coverage
- $41.30
- Patient responsibility
- $17.70
- Order total
- $59.00
Product cost(s) $35.00 · Margin $24.00 (40.7%)
Pending Approval
Approved Dec 22, 1:00 AM by Taylor Brooks
Consent and Payment
Paid — Dec 22, 2:03 AM
Ready for Vendor
Packet sent Dec 25, 12:00 AM
Placed with Vendor
Placed Dec 25, 12:00 AM
Delivered
Delivered Dec 29, 12:00 AM
Completed
POD signed Dec 30, 12:00 AM
Order closed. The page above reads top-to-bottom as this order's full history.
Activity Log
- Dec 22, 12:00 AMDraft submitted
- Dec 22, 1:00 AMApproved by Taylor Brooks
- Dec 22, 1:01 AMEncounter form generated
- Dec 22, 2:03 AMPayment recorded
- Dec 25, 12:00 AMPlaced with vendor
- Dec 29, 12:00 AMDelivered
- Dec 29, 12:00 AMPOD generated
- Dec 30, 12:00 AMPOD signed