Fatima Al-Rashid
HAL-1056via Sam Okafor, PT, DPT · Lone Star Breast Health Rehab
Intake
Submitted Nov 21, 12:00 AM
Patient Info
- Full name
- Fatima Al-Rashid
- DOB
- 01/09/1992
- f.al-rashid@example-mail.test
- Phone
- (214) 555-0122
- Shipping address
- 88 Guadalupe St Unit 4B, San Marcos, TX 78666
Health Coverage
SELF-PAY
Product Details
ProductQtyPayerPatientLine total
JOBST Bella Lite Gauntlet, 20–30 mmHg
JOBST · HCPCS A6549 · Cost $27.00
Product
JOBST Bella Lite Gauntlet, 20–30 mmHg
JOBST · HCPCS A6549
Qty1
Payer—
Patient$54.00
Line total$54.00
Calculation
- Patient responsibility
- $54.00
- Order total
- $54.00
Product cost(s) $27.00 · Margin $27.00 (50.0%)
Consent and Payment
Paid — Nov 21, 1:03 AM
Ready for Vendor
Packet sent Nov 24, 12:00 AM
Placed with Vendor
Placed Nov 24, 12:00 AM
Delivered
Delivered Nov 28, 12:00 AM
Completed
POD signed Nov 29, 12:00 AM
Order closed. The page above reads top-to-bottom as this order's full history.
Activity Log
- Nov 21, 12:00 AMDraft submitted
- Nov 21, 12:01 AMEncounter form generated
- Nov 21, 1:03 AMPayment recorded
- Nov 24, 12:00 AMPlaced with vendor
- Nov 28, 12:00 AMDelivered
- Nov 28, 12:00 AMPOD generated
- Nov 29, 12:00 AMPOD signed