Priya Chandrasekaran
HAL-1052via Dana Whitfield, PT, DPT, CLT · Austin Lymphedema & Rehab
Intake
Submitted Dec 18, 12:00 AM
Patient Info
- Full name
- Priya Chandrasekaran
- DOB
- 06/30/1979
- p.chandrasekaran@example-mail.test
- Phone
- (512) 555-0247
- Shipping address
- 1204 Barton Springs Rd, Austin, TX 78704
Health Coverage
INSURED
- Payer
- BCBS Texas
- Plan
- PPO
- Coverage %
- 85%
- Member ID
- TXP-9012844
Product Details
ProductQtyPayerPatientLine total
JOBST Bella Lite Arm Sleeve, 20–30 mmHg
JOBST · HCPCS A6549 · Cost $34.00
Product
JOBST Bella Lite Arm Sleeve, 20–30 mmHg
JOBST · HCPCS A6549
Qty1
Payer$49.30
Patient$8.70
Line total$58.00
Calculation
- Payer coverage
- $49.30
- Patient responsibility
- $8.70
- Order total
- $58.00
Product cost(s) $34.00 · Margin $24.00 (41.4%)
Consent and Payment
Paid — Dec 18, 1:03 AM
Ready for Vendor
Packet sent Dec 21, 12:00 AM
Placed with Vendor
Placed Dec 21, 12:00 AM
Delivered
Delivered Dec 25, 12:00 AM
Completed
POD signed Dec 26, 12:00 AM
Order closed. The page above reads top-to-bottom as this order's full history.
Activity Log
- Dec 18, 12:00 AMDraft submitted
- Dec 18, 12:01 AMEncounter form generated
- Dec 18, 1:03 AMPayment recorded
- Dec 21, 12:00 AMPlaced with vendor
- Dec 25, 12:00 AMDelivered
- Dec 25, 12:00 AMPOD generated
- Dec 26, 12:00 AMPOD signed