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AOL File Library: 4,101 to 4,200
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aol-file-protocol-4400-4101-to-4200.zip
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Business Management
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MEDISOFT_ V4.14a Medical Patient
/
MEDI414A.exe
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MARECPTA
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Text File
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1996-01-22
|
11KB
|
538 lines
"Format File Version 8"
"Walkout Receipt"
188
""
4,25,"ñ╒","XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX",2,3
PRINTPRAC="Y" AND PRACDOC="P"
PRNAME
"#F⌐ñY╒»#D⌐ñP╒","#L"
PRINTPRAC="Y" AND PRACDOC="D" AND BYATTEND="N"
PNAME
"#F⌐ñY╒»#D⌐ñD╒»#<⌐ñN╒","$>"
PRINTPRAC="Y" AND PRACDOC="D" AND BYATTEND="Y"
ANAME
"#F⌐ñY╒»#D⌐ñD╒»#<⌐ñY╒","%_"
""
5,25,"ñ╒","XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX",2,3
PRINTPRAC="Y" AND PRACDOC="P"
PRSTREET
"#F⌐ñY╒»#D⌐ñP╒","#M"
PRINTPRAC="Y" AND PRACDOC="D" AND BYATTEND="N"
PSTREET
"#F⌐ñY╒»#D⌐ñD╒»#<⌐ñN╒","$?"
PRINTPRAC="Y" AND PRACDOC="D" AND BYATTEND="Y"
ASTREET
"#F⌐ñY╒»#D⌐ñD╒»#<⌐ñY╒","%`"
""
6,22,"ñ╒","XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX",2,3
PRINTPRAC="Y" AND PRACDOC="P"
PRCITYLN
"#F⌐ñY╒»#D⌐ñP╒","#N"
PRINTPRAC="Y" AND PRACDOC="D" AND BYATTEND="N"
PCITYLN
"#F⌐ñY╒»#D⌐ñD╒»#<⌐ñN╒","$@"
PRINTPRAC="Y" AND PRACDOC="D" AND BYATTEND="Y"
ACITYLN
"#F⌐ñY╒»#D⌐ñD╒»#<⌐ñY╒","%a"
""
7,33,"ñ╒","XXXXXXXXXXXXXX",2,3
PRINTPRAC="Y" AND PRACDOC="P"
PRPHONE
"#F⌐ñY╒»#D⌐ñP╒","#R"
PRINTPRAC="Y" AND PRACDOC="D" AND BYATTEND="N"
PPHONE
"#F⌐ñY╒»#D⌐ñD╒»#<⌐ñN╒","$D"
PRINTPRAC="Y" AND PRACDOC="D" AND BYATTEND="Y"
APHONE
"#F⌐ñY╒»#D⌐ñD╒»#<⌐ñY╒","%e"
SYSDATE
7,67,"#6","XX-XX-XX",0,0
""
8,27,"ñ╒","XXXXXXXXXXXXXXXXXXXXXXXXXXX",2,3
PRINTPRAC="Y" AND PRACDOC="P"
"Federal ID: "+PRFEDID
"#F⌐ñY╒»#D⌐ñP╒","ñFederal ID: ╒ª#S"
PRINTPRAC="Y" AND PRACDOC="D" AND BYATTEND="N"
"License #: "+PLICENSE
"#F⌐ñY╒»#D⌐ñD╒»#<⌐ñN╒","ñLicense #: ╒ª$G"
PRINTPRAC="Y" AND PRACDOC="D" AND BYATTEND="Y"
"License #: "+ALICENSE
"#F⌐ñY╒»#D⌐ñD╒»#<⌐ñY╒","ñLicense #: ╒ª%h"
""
9,28,"ñ╒","XXXXXXXXXXXXXXXXXXXXXXXXX",2,3
PRINTPRAC="Y" AND PRACDOC="P"
""
"#F⌐ñY╒»#D⌐ñP╒","ñ╒"
PRINTPRAC="Y" AND PRACDOC="D" AND BYATTEND="N"
"PIN: "+PPIN
"#F⌐ñY╒»#D⌐ñD╒»#<⌐ñN╒","ñPIN: ╒ª$J"
PRINTPRAC="Y" AND PRACDOC="D" AND BYATTEND="Y"
"PIN: "+APIN
"#F⌐ñY╒»#D⌐ñD╒»#<⌐ñY╒","ñPIN: ╒ª%k"
""
10,24,"ñ╒","XXXXXXXXXXXXXXXXXX",1,2
AFTXIND="S"
"Social Security #:"
"%f⌐ñS╒","ñSocial Security #:╒"
AFTXIND="E"
"Federal Tax ID#:"
"%f⌐ñE╒","ñFederal Tax ID#:╒"
""
10,43,"ñ╒","XXXXXXXXXXXX",0,2
PRINTPRAC="Y" AND PRACDOC="D" AND BYATTEND="N"
PSSN
"#F⌐ñY╒»#D⌐ñD╒»#<⌐ñN╒","$F"
PRINTPRAC="Y" AND PRACDOC="D" AND BYATTEND="Y"
ASSN
"#F⌐ñY╒»#D⌐ñD╒»#<⌐ñY╒","%g"
"Patient:"
13,3,"ñPatient:╒","XXXXXXXX",0,0
CHART
13,12,"#V","XXXXXXXX",0,0
PHONE
13,22,"#a","XXXXXXXXXXXXXX",0,0
"Diagnosis"
13,51,"ñDiagnosis╒","XXXXXXXXX",0,0
"1."
14,40,"ñ1.╒","XX",0,0
DIAGLINE
14,43,"%:","XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
NAME
15,6,"#W","XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
"2."
15,40,"ñ2.╒","XX",0,0
DIAGLINE
15,43,"%:","XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
STREET
16,6,"#[","XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
"3."
16,40,"ñ3.╒","XX",0,0
DIAGLINE
16,43,"%:","XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
CITYLN
17,6,"#\","XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
"4."
17,40,"ñ4.╒","XX",0,0
DIAGLINE
17,43,"%:","XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
20,3,"","Instructions: Complete the patient information portion of your own",0,0
21,18,"","insurance claim form. Attach this bill, signed and dated,",0,0
22,18,"","and all other bills pertaining to the claim. If you have a",0,0
23,18,"","deductible policy, hold your claim forms until you have met",0,0
24,18,"","your deductible. Mail directly to your insurance carrier.",0,0
26,1,"","-------------------------------------------------------------------------------",0,0
27,4,"","Date",0,0
27,12,"","Description",0,0
27,39,"","Procedure",0,0
27,50,"","Modify",0,0
27,59,"","DX",0,0
27,63,"","Units Charge",0,0
28,1,"","-------------------------------------------------------------------------------",0,0
DATE
29,3,"%;","XX-XX-XX",0,0
DESC
29,12,"%K","XXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
CODEONLY
29,39,"%@","XXXXXXXXXX",0,0
MODIF
29,50,"%A","XXXXXX",0,0
DIAGPTR
29,58,"%O","XXXX",0,0
UNITS
29,64,"%P","XXX",0,0
AMOUNT
29,69,"%R","XXXXXX.XX",1,0
DATE
30,3,"%;","XX-XX-XX",0,0
DESC
30,12,"%K","XXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
CODEONLY
30,39,"%@","XXXXXXXXXX",0,0
MODIF
30,50,"%A","XXXXXX",0,0
DIAGPTR
30,58,"%O","XXXX",0,0
UNITS
30,64,"%P","XXX",0,0
AMOUNT
30,69,"%R","XXXXXX.XX",1,0
DATE
31,3,"%;","XX-XX-XX",0,0
DESC
31,12,"%K","XXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
CODEONLY
31,39,"%@","XXXXXXXXXX",0,0
MODIF
31,50,"%A","XXXXXX",0,0
DIAGPTR
31,58,"%O","XXXX",0,0
UNITS
31,64,"%P","XXX",0,0
AMOUNT
31,69,"%R","XXXXXX.XX",1,0
DATE
32,3,"%;","XX-XX-XX",0,0
DESC
32,12,"%K","XXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
CODEONLY
32,39,"%@","XXXXXXXXXX",0,0
MODIF
32,50,"%A","XXXXXX",0,0
DIAGPTR
32,58,"%O","XXXX",0,0
UNITS
32,64,"%P","XXX",0,0
AMOUNT
32,69,"%R","XXXXXX.XX",1,0
DATE
33,3,"%;","XX-XX-XX",0,0
DESC
33,12,"%K","XXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
CODEONLY
33,39,"%@","XXXXXXXXXX",0,0
MODIF
33,50,"%A","XXXXXX",0,0
DIAGPTR
33,58,"%O","XXXX",0,0
UNITS
33,64,"%P","XXX",0,0
AMOUNT
33,69,"%R","XXXXXX.XX",1,0
DATE
34,3,"%;","XX-XX-XX",0,0
DESC
34,12,"%K","XXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
CODEONLY
34,39,"%@","XXXXXXXXXX",0,0
MODIF
34,50,"%A","XXXXXX",0,0
DIAGPTR
34,58,"%O","XXXX",0,0
UNITS
34,64,"%P","XXX",0,0
AMOUNT
34,69,"%R","XXXXXX.XX",1,0
DATE
35,3,"%;","XX-XX-XX",0,0
DESC
35,12,"%K","XXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
CODEONLY
35,39,"%@","XXXXXXXXXX",0,0
MODIF
35,50,"%A","XXXXXX",0,0
DIAGPTR
35,58,"%O","XXXX",0,0
UNITS
35,64,"%P","XXX",0,0
AMOUNT
35,69,"%R","XXXXXX.XX",1,0
DATE
36,3,"%;","XX-XX-XX",0,0
DESC
36,12,"%K","XXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
CODEONLY
36,39,"%@","XXXXXXXXXX",0,0
MODIF
36,50,"%A","XXXXXX",0,0
DIAGPTR
36,58,"%O","XXXX",0,0
UNITS
36,64,"%P","XXX",0,0
AMOUNT
36,69,"%R","XXXXXX.XX",1,0
DATE
37,3,"%;","XX-XX-XX",0,0
DESC
37,12,"%K","XXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
CODEONLY
37,39,"%@","XXXXXXXXXX",0,0
MODIF
37,50,"%A","XXXXXX",0,0
DIAGPTR
37,58,"%O","XXXX",0,0
UNITS
37,64,"%P","XXX",0,0
AMOUNT
37,69,"%R","XXXXXX.XX",1,0
DATE
38,3,"%;","XX-XX-XX",0,0
DESC
38,12,"%K","XXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
CODEONLY
38,39,"%@","XXXXXXXXXX",0,0
MODIF
38,50,"%A","XXXXXX",0,0
DIAGPTR
38,58,"%O","XXXX",0,0
UNITS
38,64,"%P","XXX",0,0
AMOUNT
38,69,"%R","XXXXXX.XX",1,0
DATE
39,3,"%;","XX-XX-XX",0,0
DESC
39,12,"%K","XXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
CODEONLY
39,39,"%@","XXXXXXXXXX",0,0
MODIF
39,50,"%A","XXXXXX",0,0
DIAGPTR
39,58,"%O","XXXX",0,0
UNITS
39,64,"%P","XXX",0,0
AMOUNT
39,69,"%R","XXXXXX.XX",1,0
DATE
40,3,"%;","XX-XX-XX",0,0
DESC
40,12,"%K","XXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
CODEONLY
40,39,"%@","XXXXXXXXXX",0,0
MODIF
40,50,"%A","XXXXXX",0,0
DIAGPTR
40,58,"%O","XXXX",0,0
UNITS
40,64,"%P","XXX",0,0
AMOUNT
40,69,"%R","XXXXXX.XX",1,0
DATE
41,3,"%;","XX-XX-XX",0,0
DESC
41,12,"%K","XXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
CODEONLY
41,39,"%@","XXXXXXXXXX",0,0
MODIF
41,50,"%A","XXXXXX",0,0
DIAGPTR
41,58,"%O","XXXX",0,0
UNITS
41,64,"%P","XXX",0,0
AMOUNT
41,69,"%R","XXXXXX.XX",1,0
DATE
42,3,"%;","XX-XX-XX",0,0
DESC
42,12,"%K","XXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
CODEONLY
42,39,"%@","XXXXXXXXXX",0,0
MODIF
42,50,"%A","XXXXXX",0,0
DIAGPTR
42,58,"%O","XXXX",0,0
UNITS
42,64,"%P","XXX",0,0
AMOUNT
42,69,"%R","XXXXXX.XX",1,0
DATE
43,3,"%;","XX-XX-XX",0,0
DESC
43,12,"%K","XXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
CODEONLY
43,39,"%@","XXXXXXXXXX",0,0
MODIF
43,50,"%A","XXXXXX",0,0
DIAGPTR
43,58,"%O","XXXX",0,0
UNITS
43,64,"%P","XXX",0,0
AMOUNT
43,69,"%R","XXXXXX.XX",1,0
DATE
44,3,"%;","XX-XX-XX",0,0
DESC
44,12,"%K","XXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
CODEONLY
44,39,"%@","XXXXXXXXXX",0,0
MODIF
44,50,"%A","XXXXXX",0,0
DIAGPTR
44,58,"%O","XXXX",0,0
UNITS
44,64,"%P","XXX",0,0
AMOUNT
44,69,"%R","XXXXXX.XX",1,0
DATE
45,3,"%;","XX-XX-XX",0,0
DESC
45,12,"%K","XXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
CODEONLY
45,39,"%@","XXXXXXXXXX",0,0
MODIF
45,50,"%A","XXXXXX",0,0
DIAGPTR
45,58,"%O","XXXX",0,0
UNITS
45,64,"%P","XXX",0,0
AMOUNT
45,69,"%R","XXXXXX.XX",1,0
DATE
46,3,"%;","XX-XX-XX",0,0
DESC
46,12,"%K","XXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
CODEONLY
46,39,"%@","XXXXXXXXXX",0,0
MODIF
46,50,"%A","XXXXXX",0,0
DIAGPTR
46,58,"%O","XXXX",0,0
UNITS
46,64,"%P","XXX",0,0
AMOUNT
46,69,"%R","XXXXXX.XX",1,0
48,50,"","Total Charges:",0,0
CHARGES
48,65,"#-","XXXXXXXXX.XX",1,0
49,50,"","Total Credits:",0,0
PAYMENTS
49,65,"#.","XXXXXXXXX.XX",1,0
50,58,""," Tax: ",0,0
TAX
50,65,"#/","XXXXXXXXX.XX",1,0
51,43,"","Total Due This Visit:",0,0
DUE
51,65,"#0","XXXXXXXXX.XX",1,0
53,42,""," P",0,0
53,44,"","rior",0,0
53,48,""," ",0,0
53,49,"","Family Balance: ",0,0
BALANCE
53,65,"#,","XXXXXXXXX.XX",1,0
54,45,"","Family Balance Due:",0,0
SUM(DUE,BALANCE)
54,65,"╝#0º#,¿","XXXXXXXXX.XX",1,1
SUM(DUE,BALANCE)=0
"000"
"╝#0º#,¿⌐Ñ0╒","ñ000╒"
55,1,"","===============================================================================",0,0
""
56,3,"ñ╒","XXXXXXXXXXXXXXXXXXX",0,1
ACCASSIGN="Y" OR ACASSIGNB="Y" OR ACASSIGNC="Y"
"Assign and Release:"
"$1⌐ñY╒░$2⌐ñY╒░$3⌐ñY╒","ñAssign and Release:╒"
""
56,23,"ñ╒","XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX",0,1
ACCASSIGN="Y" OR ACASSIGNB="Y" OR ACASSIGNC="Y"
"I hereby authorize payment of medical benefits to this"
"$1⌐ñY╒░$2⌐ñY╒░$3⌐ñY╒","ñI hereby authorize payment of medical benefits to this╒"
""
57,23,"ñ╒","XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX",0,1
ACCASSIGN="Y" OR ACASSIGNB="Y" OR ACASSIGNC="Y"
"physician for the services described above. I also"
"$1⌐ñY╒░$2⌐ñY╒░$3⌐ñY╒","ñphysician for the services described above. I also╒"
""
58,23,"ñ╒","XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX",0,1
ACCASSIGN="Y" OR ACASSIGNB="Y" OR ACASSIGNC="Y"
"authorize the release of any information necessary to"
"$1⌐ñY╒░$2⌐ñY╒░$3⌐ñY╒","ñauthorize the release of any information necessary to╒"
""
59,23,"ñ╒","XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX",0,1
ACCASSIGN="Y" OR ACASSIGNB="Y" OR ACASSIGNC="Y"
"process this claim."
"$1⌐ñY╒░$2⌐ñY╒░$3⌐ñY╒","ñprocess this claim.╒"
""
61,3,"ñ╒","XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX",0,1
ACCASSIGN="Y" OR ACASSIGNB="Y" OR ACASSIGNC="Y"
"Patient Signature: __________________________________"
"$1⌐ñY╒░$2⌐ñY╒░$3⌐ñY╒","ñPatient Signature: __________________________________╒"
""
61,61,"ñ╒","XXXXXXXXXXXXXXX",0,1
ACCASSIGN="Y" OR ACASSIGNB="Y" OR ACASSIGNC="Y"
"Date: _________"
"$1⌐ñY╒░$2⌐ñY╒░$3⌐ñY╒","ñDate: _________╒"
""
63,1,"ñ╒","XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX",0,1
ACCASSIGN="Y" OR ACASSIGNB="Y" OR ACASSIGNC="Y"
"==============================================================="
"$1⌐ñY╒░$2⌐ñY╒░$3⌐ñY╒","ñ===============================================================╒"
""
63,64,"ñ╒","XXXXXXXXXXXXXXXX",0,1
ACCASSIGN="Y" OR ACASSIGNB="Y" OR ACASSIGNC="Y"
"================"
"$1⌐ñY╒░$2⌐ñY╒░$3⌐ñY╒","ñ================╒"
18
4
20
66
"66"
79
"79"
0
"0"
""
DATE,DOC
"%^%;%="
""
"%^"
""
""
Y
"Y"
N
"N"
N
"N"
N
"N"
Y
"Y"
N
"N"
Y
"Y"
D
"D"
Y
"Y"
Y
"Y"
TAX
"TAX"
18
"","Y"
"","Y"
"","Y"
"","Y"
"","Y"
"","Y"
"","Y"
"","Y"
"","Y"
"","Y"
"","Y"
"N","Y"
"","Y"
"","N"
"","N"
"","N"
"","N"
"","Y"