Leo Castellanos
HAL-1050via Priya Anand, DPT, CLT · Central Texas Lymphatic Therapy
Intake
Submitted Dec 21, 12:00 AM
Patient Info
- Full name
- Leo Castellanos
- DOB
- 12/27/1988
- l.castellanos@example-mail.test
- Phone
- (512) 555-0264
- Shipping address
- 740 Cypress Creek Rd, Cedar Park, TX 78613
Health Coverage
SELF-PAY
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—
Patient$92.95
Line total$92.95
Calculation
- Patient responsibility
- $92.95
- Order total
- $92.95
Product cost(s) $46.00 · Margin $46.95 (50.5%)
Consent and Payment
Paid — Dec 21, 1:03 AM
Ready for Vendor
Packet sent Dec 24, 12:00 AM
Placed with Vendor
Placed Dec 24, 12:00 AM
Delivered
Delivered Dec 28, 12:00 AM
Completed
POD signed Dec 29, 12:00 AM
Order closed. The page above reads top-to-bottom as this order's full history.
Activity Log
- Dec 21, 12:00 AMDraft submitted
- Dec 21, 12:01 AMEncounter form generated
- Dec 21, 1:03 AMPayment recorded
- Dec 24, 12:00 AMPlaced with vendor
- Dec 28, 12:00 AMDelivered
- Dec 28, 12:00 AMPOD generated
- Dec 29, 12:00 AMPOD signed