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JCSM Shareware Collection 1996 September
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JCSM Shareware Collection (JCS Distribution) (September 1996).ISO
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medhelth
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13770a01.zis
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SCREEN.009
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1995-07-12
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2KB
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26 lines
1.00 Abraczinskas, Donald
Financial │ Marital status │ Employed │ Student status │ Seen 1st: 12/20/91
class: C │ (S/M/O): M │ (Y/N): Y │ (F/P/blank): │ last: 06/14/95
───────────┴────────────────┴──────────┴──────────────────┼───────────────────
Code table assigned: 00 STANDARD ACCOUNTING CODES │ CHAMPUS sponsor
Assigned to Dr. #..: 00 FIRST DOCTOR ON FILE │ Status...: A
Referred by Dr. #..: 00 FIRST DOCTOR ON FILE │ Branch...: M
Referred by other.....: │ Pay grade: 05
──────────────────────────────────────────────────────────┴───────────────────
Insurance provider patient #.....: 01 Abraczinskas, MARY
Relationship to patient (X/S/P/O): P PARENT
AARP Prudential AARP
Insurance Company #1..: 15001 │ Insurance Company #2..: 15025
Insured's ID.: 123456789012345 │ Insured's ID.: AAAAAAAAAAAAAAA
Policy #.....: 123456789012345678 │ Policy #.....: BBBBBBBBBBBBBBBBBB
Group #......: 123456789012345 │ Group #......: CCCCCCCCCCCCCCC
Ins. claim type.: 1 MEDICARE │ Ins. claim type.: 2 MEDICAID
MEDIGAP/Employer Sup.(M/S): │ MEDIGAP/Employer Sup.(M/S):
──────────────────────────────────────┴───────────────────────────────────────
Assignment accepted (Y/N): Y %: 100 Co.: 15001 Signature date: 06/15/92
──────────────────────────────────────────────────────────────────────────────
Discount percent given: 0.0 Finance charges (Y/N): N Taxable (Y/N): N
Billing cycle code....: (R)egular, (B)udget, or (C)orporate ....: R
Print statement (Y/N).: Y Budget payment amount: 0.00 1st: / /