Grant Whitmore
HAL-1055via Dana Whitfield, PT, DPT, CLT · Austin Lymphedema & Rehab
Intake
Submitted Dec 3, 12:00 AM
Patient Info
- Full name
- Grant Whitmore
- DOB
- 07/16/1961
- g.whitmore@example-mail.test
- Phone
- (512) 555-0158
- Shipping address
- 3300 Duval St Apt 12, Austin, TX 78705
Health Coverage
INSURED
- Payer
- UnitedHealthcare
- Plan
- Choice Plus
- Coverage %
- 80%
- Member ID
- UHC-33920671
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$47.20
Patient$11.80
Line total$59.00
Calculation
- Payer coverage
- $47.20
- Patient responsibility
- $11.80
- Order total
- $59.00
Product cost(s) $35.00 · Margin $24.00 (40.7%)
Pending Approval
Approved Dec 3, 1:00 AM by Taylor Brooks
Consent and Payment
Paid — Dec 3, 2:03 AM
Ready for Vendor
Packet sent Dec 6, 12:00 AM
Placed with Vendor
Placed Dec 6, 12:00 AM
Delivered
Delivered Dec 10, 12:00 AM
Completed
POD signed Dec 11, 12:00 AM
Order closed. The page above reads top-to-bottom as this order's full history.
Activity Log
- Dec 3, 12:00 AMDraft submitted
- Dec 3, 1:00 AMApproved by Taylor Brooks
- Dec 3, 1:01 AMEncounter form generated
- Dec 3, 2:03 AMPayment recorded
- Dec 6, 12:00 AMPlaced with vendor
- Dec 10, 12:00 AMDelivered
- Dec 10, 12:00 AMPOD generated
- Dec 11, 12:00 AMPOD signed