Billing Version 0.0089897

87875644456

  • Case Name : Case Name Here
    Total Visits : 04
  • Referring Physician : Mark B William
    Phone : (676) 909-8989
    Fax : (676) 909-8989
    Doctor's Orders Expires : 08/20/2018
    Total Visits : 07
    Visit Used : 04
    Visits Left : 03
  • * Authorization Expires : 08/20/2018
    Total Visits : 07
    Visit Used : 04
    Visits Left : 03
    Auth# : 0679967867
  • Insurance Eligible Through : 08/20/2018
    Eligibilty Comments : Comments Here...
Date of Birth: 12/02/1978 (38)
Ins Class: Medicare
Ins Name: Max Bupa

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Patient Information

Chris J Allan Sr
Chris
Town Place, 9625 Milliken Ave, Rancho Cucamonga, Ontario, CA 91730, USA

Phone

(898) 888 - 8989
(898) 888 - 8989
(898) 888 - 8989
Home

Other Contact Information

ChrisJAllan_Sr1962@gmail.com
Voice

Other Patient Information

9/11/1987
Male
908 999 7878
Single
787854767
English
Bros. Corporation

Internal Information

Please type your comment here !
89546654678

Emergency Contact

Mark S Peterson
(234) 999 - 9098
(234) 999 - 9545
(234) 999 - 9232

Responsible Party

Chris J Allan Sr
Town Place, 9625 Milliken Ave, Rancho Cucamonga, Ontario, CA 91730, USA
ChrisJAllan_Sr1962@gmail.com
(234) 999 - 5656
9/11/1987
Male
908 999 7878
Single
787854767
0996768457

Billing Information

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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
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Financial

Account Summary

Charge Amount Payment Amount Adjustment Amount Balance
Insurance $222.05 $0.00 $0.00 $222.05
Patient $0.00 $45.00 $0.00 -$45.05
Total $222.05 $45.00 $0.00 $177.05

Ledger Full

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Ledger Visit

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Visit Log

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Billing History

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Demand Statement

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Form Letters

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Statement and Payments

Patient Statement Log

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Patient Payment Log

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Cases


Case Insurance Visits With Charges Dates Status
  ID Name Primary Secondary Tertiary Count DOS From DOS To Injury/Onset Discharge Case Effective Effective End Incomplete Active
9988261 06/15/2016 Shoulder Aetna Medicare 3 06/15/16 06/30/16 06/15/2016 06/15/2016 06/15/2016 06/15/2016
Referring Physician: Jonathan Higginsworth
Primary Insurance Secondary Insurance Tertiary Insurance
Name Aetna Medicare Blue Cross
Insurance Class MH MH
Payer Group Capario Capario
Group # 123456789 987654321
Policy # 987654321 123456789
Address 9994 SW Pine St.
Suite 240
Portland, OR 97777-7777 		3345 NE Wilson Rd.
San Diego, CA 92222-2222
Phone 555-555-5555 555-555-5555
Subscriber Gale, Dorothy Henry Gale
Relationship Self Father
Address 123 W. Main St.
Apt. 24
Kansas City, KS 97777-7777 		123 W. Main St.
Apt. 24
Kansas City, KS 97777-7777
DOB 12/20/1967 01/16/1966
SSN 999-999-9999 999-999-9999
Gender F M
6668891 010/02/2016 Shoulder Paradise Medicare Medico Medicare Metro Medicare 3 06/15/16 06/30/16 06/15/2016 06/15/2016 06/15/2016 06/15/2016
3466891 04/02/2016 Shoulder Aetna Medicare Medico Medicare Metro Medicare 3 06/15/16 06/30/16 06/15/2016 06/15/2016 06/15/2016 06/15/2016
New Case

Account Notes

Note Type Date Due Date Created by Assignee Status Stuck on
This patient's credit card is expired. INFO 02/26/2016 02/26/2016 Sampson, George Mark, Bill Incomplete --Not a Sticky--

Medical Record

Output Reports

Name Note DOS Type Created Date Status
05/26/2016 - SELF PAY
Non-Visit Discharge Note - 7/11/2016 11:41 AM Non Visit Discharge 7/11/2016 7/11/2016 Final
Initial Visit Note - 6/28/2016 1:18 PM Evaluation Visit Note 6/28/2016 6/28/2016 Final
POC Certification_NonMedicare - 6/28/2016 1:18 PM Evaluation Visit Note 6/28/2016 6/28/2016 Final
06/03/2015 - Foot Pain
06/03/2015 - Wrist Pain

Scanned Documents

Date Created Document Name Image Type Category Type Document Date Case ID Case
06/03/2015 3:38:10 PM FOTO Intake report 06/04/2015 3466758 06/03/2015 -Foot Pain

Print Patient Forms

Date Created Document Name Location Practice
06/03/2015 3:38:10 PM Patient Intake Form BMS Testing ZZX Berk PLSC Alta Vista Rehab
07/10/2015 10:25:37 PM Back Disability Index Form Happy PT




 
 
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