Odalys Reyes
HAL-1054via Priya Anand, DPT, CLT · Central Texas Lymphatic Therapy
Intake
Submitted Dec 9, 12:00 AM
Patient Info
- Full name
- Odalys Reyes
- DOB
- 03/21/1983
- o.reyes@example-mail.test
- Phone
- (512) 555-0296
- Shipping address
- 5501 Balcones Dr Ste 210, Austin, TX 78731
Health Coverage
INSURED
- Payer
- Aetna
- Plan
- Choice POS II
- Coverage %
- 75%
- Member ID
- AET-4471029
Product Details
ProductQtyPayerPatientLine total
Juzo Basic Gauntlet
Juzo · HCPCS A6549 · Cost $13.00
Product
Juzo Basic Gauntlet
Juzo · HCPCS A6549
Qty2
Payer$34.50
Patient$11.50
Line total$46.00
Calculation
- Payer coverage
- $34.50
- Patient responsibility
- $11.50
- Order total
- $46.00
Product cost(s) $26.00 · Margin $20.00 (43.5%)
Consent and Payment
Paid — Dec 9, 1:03 AM
Ready for Vendor
Packet sent Dec 12, 12:00 AM
Placed with Vendor
Placed Dec 12, 12:00 AM
Delivered
Delivered Dec 16, 12:00 AM
Completed
POD signed Dec 17, 12:00 AM
Order closed. The page above reads top-to-bottom as this order's full history.
Activity Log
- Dec 9, 12:00 AMDraft submitted
- Dec 9, 12:01 AMEncounter form generated
- Dec 9, 1:03 AMPayment recorded
- Dec 12, 12:00 AMPlaced with vendor
- Dec 16, 12:00 AMDelivered
- Dec 16, 12:00 AMPOD generated
- Dec 17, 12:00 AMPOD signed