Norman Blake

Transactions

Session			Payments & Adjustments						Balance:	Notes
			Sent			Received			$295.87
Date	Type	Fee	Date Submitted	Sent To	Type	Date Received	Payor	Amt	Session Balance
10/1/06	90806	$100.00				10/1/06	Client	$20.00	$80.00	Client’s co-pay is $20 but still owes some on deductible.
			10/1/06	BC/BS	e-File	10/28/06	BC/BS	$30.00	$50.00	Have submitted to Aetna
			10/28/06	Aetna	Paper	11/20/06	Aetna	$20.00	$30.00
9/8/06	90847	$120.00							$120.00	Forgot the checkbook; will pay next week.
						9/15/06	Client	$10.00	$110.00	Only paid half of his co-pay; will need to bill for the rest.
			9/15/06	BC/BS	e-File	10/8/06	BC/BS	$0.00	$110.00	BC/BS doesn’t pay for 90847. Have submitted to Aetna
			9/15/06	Client	Paper	10/17/06	Client	$10.00	$100.00
			10/8/06	Aetna	Paper	10/23/06	Aetna	$90.00	$10.00
					Adjustment	8/20/06	Write-off	$10.00	$0.00
7/15/06	Client No-show	$100.00							$100.00	Norman knows he's responsible for this amount.

Demographics

DOB: Oct 10, 1987 Phone: 220-205-9876 Insurance: Blue Choice Insurance ID: #BA5330AG71-01

Phones

Cell:
Home:
Work:
Other:

Personal Info:

First Name: Middle: Last Name:

Street Address: Apt, etc:

City: State: Zip: Birthdate:

Preferred Email: Other Email:

SSN: Fax: Male Female

Emergency Contact Info:

Name: Phone 1: Phone 2: Relationship:

Notes:

Referred by Jessie Odowan.

Insurance

DOB: Oct 10, 1987 Phone: 220-205-9876 Insurance: Blue Choice Insurance ID: #BA5330AG71-01

Phones

Main:
Authorizations:
Fax:
Other:

Company Name:

Street Address:

Street Address 2:

City: State: Zip:

Provider ID:

Plan Type:

Notes:

Family Info

DOB: Oct 10, 1987 Phone: 220-205-9876 Insurance: Blue Choice Insurance ID: #BA5330AG71-01

Spouse/Partner/Significant Other:

First Name: Middle: Last Name: Occupation:

Children:

First Name: Middle: Last Name: Age: Male Female

Parents:

MOTHER

First Name: Last Name: Occupation:

FATHER

First Name: Last Name: Occupation:

Siblings:

First Name: Last Name: Age: Occupation: Male Female

Payment Setup

DOB: Oct 10, 1987 Phone: 220-205-9876 Insurance: Blue Choice Insurance ID: #BA5330AG71-01

Content from template for payment setup.

Appointments

DOB: Oct 10, 1987 Phone: 220-205-9876 Insurance: Blue Choice Insurance ID: #BA5330AG71-01

Date	Time		Therapist
	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

Other

DOB: Oct 10, 1987 Phone: 220-205-9876 Insurance: Blue Choice Insurance ID: #BA5330AG71-01

This is a place for user-defined information on clients to appear.

DOB: Oct 10, 1987 Phone: 220-205-9876 Insurance: Blue Choice Insurance ID: #BA5330AG71-01

Clients

Transactions

Session

Payments & Adjustments

Balance:

Notes

Demographics

DOB: Oct 10, 1987 Phone: 220-205-9876 Insurance: Blue Choice Insurance ID: #BA5330AG71-01

Insurance

DOB: Oct 10, 1987 Phone: 220-205-9876 Insurance: Blue Choice Insurance ID: #BA5330AG71-01

Family Info

DOB: Oct 10, 1987 Phone: 220-205-9876 Insurance: Blue Choice Insurance ID: #BA5330AG71-01

MOTHER

FATHER

Payment Setup

DOB: Oct 10, 1987 Phone: 220-205-9876 Insurance: Blue Choice Insurance ID: #BA5330AG71-01

Appointments

DOB: Oct 10, 1987 Phone: 220-205-9876 Insurance: Blue Choice Insurance ID: #BA5330AG71-01

Other

DOB: Oct 10, 1987 Phone: 220-205-9876 Insurance: Blue Choice Insurance ID: #BA5330AG71-01