Add Patient

Emergency Contact
Responsible Party
Medicare Cap

Patient Information

First Name (required)

Last Name (required)

Suffix

Preferred Name

Location

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 (entry of at least one phone number required)

Home

Cell

Work

Primary Phone

Other Contact Information

Reminder Type

Other Patient Information

Date of Birth (required)

Gender (required)

SSN (required) required for billing

Marital Status

Driver's License

Spoken Language

Requested Provider

Internal Information

Comment

Alternate Patient ID

Emergency Contact

First Name

Last Name

Phone

Home

Cell

Work

Responsible Party

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 (required) required for billing

Date of Birth

Gender

SSN

Marital Status

Driver's License

Health Savings Account

Billing Information

Do not send batch statement to patient

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.

Patient Active

Medicare Cap

Enter the dollar amount applied toward the Medicare cap to date for the specified year for therapy services not billed through RevFlow.

	Year	Amount	Specialty
	widget for selecting year	dollar field	dropdown to select PT/SLP or OT
	widget for selecting year	dollar field	dropdown to select PT/SLP or OT

	Appointment Time	Patient	Arrival Time
	9:00 AM	Smith, Suzie	8:47 AM
	9:00 AM	Doe, John	9:01 AM