Connor Mabry
HAL-1057via Marcus Ilford, PT, CLT · Hill Country Cancer Rehab
Intake
Submitted Nov 6, 12:00 AM
Patient Info
- Full name
- Connor Mabry
- DOB
- 11/28/1966
- c.mabry@example-mail.test
- Phone
- (512) 555-0233
- Shipping address
- 915 Ranch Rd 620 N, Round Rock, TX 78681
Health Coverage
INSURED
- Payer
- Medicare
- Plan
- Original Medicare Part B
- Coverage %
- 90%
- Member ID
- 3JK7-VG2-PQ45
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 Nov 6, 1:00 AM by Taylor Brooks
Consent and Payment
Paid — Nov 6, 2:03 AM
Ready for Vendor
Packet sent Nov 9, 12:00 AM
Placed with Vendor
Placed Nov 9, 12:00 AM
Delivered
Delivered Nov 13, 12:00 AM
Completed
POD signed Nov 14, 12:00 AM
Order closed. The page above reads top-to-bottom as this order's full history.
Activity Log
- Nov 6, 12:00 AMDraft submitted
- Nov 6, 1:00 AMApproved by Taylor Brooks
- Nov 6, 1:01 AMEncounter form generated
- Nov 6, 2:03 AMPayment recorded
- Nov 9, 12:00 AMPlaced with vendor
- Nov 13, 12:00 AMDelivered
- Nov 13, 12:00 AMPOD generated
- Nov 14, 12:00 AMPOD signed