Norman Blake

Clients

	Session				Payments & Adjustments							Balances	Notes
					Sent				Received			TOTAL: $743.27
All	Date		Type	Fee	Date Submitted	Sent To	Amount	Type	Date Received	Payor	Amt	Session Balance
		10/1/06	90806	$100.00					Total	received:	$70.00	$30.00	Client’s co-pay is $20 but still owes some on deductible.
					10/1/06	BC/BS	$100.00	e-File	10/28/06	BC/BS	$30.00	$50.00	Have submitted to Aetna
					10/1/06	BC/BS	$100.00	e-File	10/28/06	BC/BS	$30.00	$50.00	Have submitted to Aetna
					10/28/06	Aetna	$70.00	Statement	11/20/06	Aetna	$20.00	$30.00

Personal Info

First Name:** Middle: Last Name:**

Contact Info

Street Address: Apt, etc:

City: State: Zip:

Birthdate: Age: SSN: Gender: Male Female

Emergency Contact Info

First Name: Last Name: Phone 1: Phone 2: Relationship:

Notes

Insurance #1

Phones

Company Name:

Street Address:

Street Address 2:

City: State: Zip:

Provider ID:

Plan Type:

Notes:

All	Date	Time		Therapist
All		Start	End
	1/15/07	3:00pm	3:50pm	Smith
	12/22/06	3:00pm	3:50pm	Smith
	10/29/06	2:00pm	2:45pm	Carter
	10/7/06	3:00pm	3:50pm	Smith
	9/15/06	4:30pm	5:20pm	Smith
	8/22/06	1:00pm	1:50pm	Carter
	8/13/06	7:00am	7:50am	Smith
	8/10/06	7:30pm	8:20pm	Smith
	7/15/06	3:00pm	3:50pm	Smith
	7/7/06	3:00pm	3:50pm	Smith
	6/29/06	2:00pm	2:45pm	Carter
	6/7/06	3:00pm	3:50pm	Smith
	5/15/06	4:30pm	5:20pm	Smith
	4/22/06	1:00pm	1:50pm	Carter
	4/13/06	7:00am	7:50am	Smith
	4/10/06	7:30pm	8:20pm	Smith
	3/31/06	3:00pm	3:50pm	Smith
	3/29/06	3:00pm	3:50pm	Smith
	3/19/06	2:00pm	2:45pm	Carter
	3/7/06	3:00pm	3:50pm	Smith
	2/28/06	4:30pm	5:20pm	Smith
	2/22/06	1:00pm	1:50pm	Carter
	2/13/06	7:00am	7:50am	Smith
	1/15/06	7:30pm	8:20pm	Smith

Date	Drug Name	Dosage	Frequency	Prescribed By	Notes
10/4/06	Zoloft	50mg	Once daily	Frank Smith, MD	Upped this from 25mg
8/14/06	Prozac	DC'd		Frank Smith, MD
10/4/06	Zoloft	25mg	Once daily	Frank Smith, MD	Switched from Prozac to this
8/14/06	Prozac	40mg	Twice daily	Frank Smith, MD