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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.011
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1995-07-12
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07/12/95 ACCOUNT/PATIENT - TRANSACTION POST 10:39:18
╔══════════╤════╤══════════════════════════════════════════════════════════════╗
║ Account │Code│ Prefix Last Name First I ║
║ 1.00 │ 01 │ Abraczinskas Donald ║
╚══════════╧════╧══════════════════════════════════════════════════════════════╝
--------------< Insurance information relative to this patient. >---------------
Insurance assignment accepted....Y/N: Y ----<Insurance carriers>----
Signature on file date..............: 06/15/92 Primary % 100 Co.: 15001
Referring Dr..: 02 James Wuamett MD Secondary Ins. Co.: 15025
(comment/date): 12345678901234567890123456 02/02/94
Information release authorized...Y/N: Y ** YES *** First symptom.....: 03/01/93
Condition result of an Accident..Y/N: Y 03/01/93 First seen........: 03/02/93
Condition related to>-Employment.Y/N: N Illness....:
>-Auto.......Y/N: N State.: Similar illness...: / /
>-Crime......Y/N: N Lab work Y/N: N Fee: 0.00
Condition an Emergency...........Y/N: N
Hospital/place of service name: X-Ray.............: / /
REN DIALYSIS CENTER, DAYTONA BEACH, FL 32114 Hospital.: 03/01/93 03/05/93
EPSDT............: N CHAMPUS Sponsor Total Dis: / / / /
Family planning..: N Status...: A Partial..: / / / /
Prior authorization Branch...: M Return to work....: / /
No.: ASDASDFADFASDFD Pay grade: 05 Death.............: / /
Information correct (Y/N): Y