Billing Version 0.0089897

Date of Birth: 12/02/1978 (38)

Ins Class: Medicare

Ins Name: Max Bupa

Case

Case Information

Case Name

Injury Type (required) required for billing

Dates

Injury/Onset Date

Start of Care Date

Discharge Date

Assignment Date (required)

required for billing

Case Effective Date (required)

required for billing

Next Doctor Visit

Patient's Physicians

Referring Physician (required)

required for billing

Second Referring Physician

Location and Provider

Location (required)

required for billing

Billing Provider (required)

required for billing

Discipline (required) required for billing

Accident Location

Internal Information

Use Special Billing

Alternate Referral Source

Referral Date

Referral Status

Special Program

Patient Contact

Patient Contact Comments

Created by	user name	on	mm/dd/yy hh:mm:ss AM
Modified by	user name	on	mm/dd/yy hh:mm:ss AM

Diagnosis

At least one ICD-10 code is required

	ICD-10 Code	Description
	selected ICD-10 code	description of selected ICD-10 code. field must autoexpand to display entire description; display cannot be truncated.
	selected ICD-10 code	description of selected ICD-10 code. field must autoexpand to display entire description; display cannot be truncated.

Primary Insurance

Insurance (required)

required for billing

Group Number (required) required for billing

Policy Number (required) required for billing

Subscriber Information

Same as Patient

First Name (required) required for billing

Last Name (required) required for billing

Suffix

Address 1 (required) required for billing

Address 2

City (required) required for billing

Country (required) required for billing

State (required) required for billing

ZIP Code (required) required for billing

Phone

SSN

Date of birth (required)

required for billing

Relationship (required) required for billing

Gender (required) required for billing

Subscriber's Employer

Name (required) required if Workers' Compensation

Address 1

Address 2

City

State

Zip Code

Phone

Subscriber Active

Primary Insurance Preauthorizations Show Inactive

	Preauthorization Number	Date Range	Number Authorized	Amount Used	Visits or Units	Active
				2	Visits Units

Doctor's Orders Show Inactive

	Date Range	Prescribed Visits	Visits Used	Comments	Active
			0

Secondary Insurance

Insurance (required)

required for billing

Group Number (required) required for billing

Policy Number (required) required for billing

Subscriber Information

Same as Patient

First Name (required) required for billing

Last Name (required) required for billing

Suffix

Address 1 (required) required for billing

Address 2

City (required) required for billing

Country (required) required for billing

State (required) required for billing

ZIP Code (required) required for billing

Phone

SSN

Date of birth (required)

required for billing

Relationship (required) required for billing

Gender (required) required for billing

Subscriber's Employer

Name

Address 1

Address 2

City

State

Zip Code

Phone

Subscriber Active

Secondary Insurance PreauthorizationsShow Inactive

	Preauthorization Number	Date Range	Number Authorized	Amount Used	Visits or Units	Active
				2	Visits Units

Tertiary Insurance

Insurance (required)

required for billing

Group Number (required) required for billing

Policy Number (required) required for billing

Subscriber Information

Same as Patient

First Name (required) required for billing

Last Name(required) required for billing

Suffix

Address 1 (required) required for billing

Address 2

City (required) required for billing

Country (required) required for billing

State (required) required for billing

ZIP Code (required) required for billing

Phone

SSN

Date of birth (required)

required for billing

Relationship (required) required for billing

Gender (required) required for billing

Subscriber's Employer

Name

Address 1

Address 2

City

State

Zip Code

Phone

Subscriber Active

Tertiary Insurance PreauthorizationsShow Inactive

	Preauthorization Number	Date Range	Number Authorized	Amount Used	Visits or Units	Active
				2	Visits Units

FOTO

FOTO Episodes

Link to Case	FOTO Episode ID	Body Part	Impairment	Date Created	Therapist
	Case 1	0074		01/02/2019 11:46:56 AM	James Miller
	Case 2	0067		01/02/2019 11:46:56 AM	Chris Allan

FOTO Reports

Report Type	Survey Date
Healthcare Report	11/11/2018
Patient Report	11/11/2018

Verification Forms

Conditional Billing

Conditional
Billing Code 1

Conditional
Billing Code 2

Conditional
Billing Code 3

Conditional Billing Note

Fields marked with "required" must be completed before you can save.

Fields marked with "required for billing" do not need to be completed in order to save. However, you cannot bill charges for this patient until these fields are completed.

Case Active

Insurance Name

Insurance Code

Address 1

City

Search Results

6 of 20 records shown

Ins Code

Insurance Name

Address 1

City

Phone

Insurance Class

WellCare Health Plan

33, Crossings

Upland

(999) 999-9999

Anthem Blue Cross

WellCare Health Plan

33, Crossings

Upland

(999) 999-9999

Anthem Blue Cross

WellCare Health Plan

33, Crossings

Upland

(999) 999-9999

Anthem Blue Cross

WellCare Health Plan

33, Crossings

Upland

(999) 999-9999

Anthem Blue Cross

Source Description

Search Results

6 of 20 records shown

Source Description	Source Type
Dover Corporation, Inc.1	ATHLETES
Dover Corporation, Inc.1	ATHLETES
Dover Corporation, Inc.1	ATHLETES
Dover Corporation, Inc.1	ATHLETES
Dover Corporation, Inc.1	ATHLETES

>>>>>

Case

Case Information

Dates

Patient's Physicians

Location and Provider

Internal Information

Diagnosis

At least one ICD-10 code is required

Primary Insurance

Subscriber Information

Subscriber's Employer

Primary Insurance Preauthorizations Show Inactive

Primary Insurance EligibilityShow Inactive

Doctor's Orders Show Inactive

Secondary Insurance

Subscriber Information

Subscriber's Employer

Secondary Insurance PreauthorizationsShow Inactive

Secondary Insurance EligibilityShow Inactive

Tertiary Insurance

Subscriber Information

Subscriber's Employer

Tertiary Insurance PreauthorizationsShow Inactive

Tertiary Insurance EligibilityShow Inactive

FOTO

FOTO Episodes

FOTO Reports

Verification Forms

Conditional Billing