Ingrid Solberg
HAL-1051via Sam Okafor, PT, DPT · Lone Star Breast Health Rehab
Intake
Submitted Dec 20, 12:00 AM
Patient Info
- Full name
- Ingrid Solberg
- DOB
- 02/14/1958
- i.solberg@example-mail.test
- Phone
- (214) 555-0179
- Shipping address
- 2210 Greenville Ave, Dallas, TX 75206
Health Coverage
INSURED
- Payer
- Medicare
- Plan
- Original Medicare Part B
- Coverage %
- 90%
- Member ID
- 2FH5-UF6-NL83
Product Details
ProductQtyPayerPatientLine total
Juzo Compression Wrap Calf
Juzo · HCPCS A6531 · Cost $58.00
Product
Juzo Compression Wrap Calf
Juzo · HCPCS A6531
Qty1
Payer$85.50
Patient$9.50
Line total$95.00
Calculation
- Payer coverage
- $85.50
- Patient responsibility
- $9.50
- Order total
- $95.00
Product cost(s) $58.00 · Margin $37.00 (38.9%)
Pending Approval
Approved Dec 20, 1:00 AM by Taylor Brooks
Consent and Payment
Paid — Dec 20, 2:03 AM
Ready for Vendor
Packet sent Dec 23, 12:00 AM
Placed with Vendor
Placed Dec 23, 12:00 AM
Delivered
Delivered Dec 27, 12:00 AM
Completed
POD signed Dec 28, 12:00 AM
Order closed. The page above reads top-to-bottom as this order's full history.
Activity Log
- Dec 20, 12:00 AMDraft submitted
- Dec 20, 1:00 AMApproved by Taylor Brooks
- Dec 20, 1:01 AMEncounter form generated
- Dec 20, 2:03 AMPayment recorded
- Dec 23, 12:00 AMPlaced with vendor
- Dec 27, 12:00 AMDelivered
- Dec 27, 12:00 AMPOD generated
- Dec 28, 12:00 AMPOD signed