Nadia Osei
HAL-1058OVERDUEvia Sam Okafor, PT, DPT · Lone Star Breast Health Rehab
Intake
Submitted Dec 21, 12:00 AM
Patient Info
- Full name
- Nadia Osei
- DOB
- 04/02/1977
- n.osei@example-mail.test
- Phone
- (512) 555-0288
- Shipping address
- 2210 Greenville Ave, Dallas, TX 75206
Health Coverage
INSURED
- Payer
- Medicare
- Plan
- Original Medicare Part B
- Coverage %
- 100%
- Member ID
- 4KL8-WH3-QR56
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$46.00
Patient$0.00
Line total$46.00
Calculation
- Payer coverage
- $46.00
- Patient responsibility
- $0.00
- Order total
- $46.00
Product cost(s) $27.00 · Margin $19.00 (41.3%)
Consent and Payment
Ready for Vendor
Packet sent Dec 23, 12:00 AM
Placed with Vendor
Placed Dec 23, 12:00 AM
- Product
- JOBST Bella Lite Gauntlet, 20–30 mmHg · JOBST
- Vendor order #
- JB-50291
- Expected delivery
- Dec 30, 1969
Delivered
Completed
Activity Log
- Dec 21, 12:00 AMDraft submitted
- Dec 21, 12:01 AMEncounter form generated
- Dec 23, 12:00 AMPlaced with JOBST — order #JB-50291