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/ JCSM Shareware Collection 1996 September / JCSM Shareware Collection (JCS Distribution) (September 1996).ISO / medhelth / 13770a01.zis / SCREEN.011 < prev    next >
Text File  |  1995-07-12  |  2KB  |  26 lines
  1.                                                                                 
  2. 07/12/95              ACCOUNT/PATIENT - TRANSACTION POST                10:39:18
  3. ╔══════════╤════╤══════════════════════════════════════════════════════════════╗
  4. ║ Account  │Code│ Prefix     Last Name                        First          I ║
  5. ║     1.00 │ 01 │            Abraczinskas                     Donald           ║
  6. ╚══════════╧════╧══════════════════════════════════════════════════════════════╝
  7. --------------< Insurance information relative to this patient. >---------------
  8. Insurance assignment accepted....Y/N: Y             ----<Insurance carriers>----
  9. Signature on file date..............: 06/15/92      Primary % 100  Co.: 15001   
  10. Referring Dr..: 02 James Wuamett MD                 Secondary Ins. Co.: 15025   
  11. (comment/date): 12345678901234567890123456 02/02/94                             
  12. Information release authorized...Y/N: Y ** YES ***  First symptom.....: 03/01/93
  13. Condition result of an Accident..Y/N: Y 03/01/93    First seen........: 03/02/93
  14. Condition related to>-Employment.Y/N: N             Illness....:                
  15.                     >-Auto.......Y/N: N State.:     Similar illness...:   /  /  
  16.                     >-Crime......Y/N: N             Lab work Y/N: N Fee:    0.00
  17. Condition an Emergency...........Y/N: N                                         
  18. Hospital/place of service name:                     X-Ray.............:   /  /  
  19. REN DIALYSIS CENTER,      DAYTONA BEACH, FL 32114   Hospital.: 03/01/93 03/05/93
  20. EPSDT............: N          CHAMPUS Sponsor       Total Dis:   /  /     /  /  
  21. Family planning..: N         Status...: A           Partial..:   /  /     /  /  
  22. Prior authorization          Branch...: M           Return to work....:   /  /  
  23. No.: ASDASDFADFASDFD         Pay grade: 05          Death.............:   /  /  
  24.                                                                                 
  25.                          Information correct (Y/N): Y                           
  26.