Norman Blake

Transactions

	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					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	$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
	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	$110.00	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	$10.00	Paper	10/17/06	Client	$10.00	$100.00
				10/8/06	Aetna	$100.00	HCFA-1500	10/23/06	Aetna	$90.00	$10.00
						$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.
	7/1/06	90806	$100.00	7/1/06	Client	$20.00	Statement	7/8/06	Client	$20.00	$80.00
				7/28/06	BC/BS	$80.00	e-File				$50.00
				8/20/06	Aetna	HCFA-1500	HCFA-1500				$30.00
	6/8/06	90847	$120.00								$120.00
				7/15/06	Client	Statement	Statement				$110.00
				7/28/06	BC/BS	$0.00	$0.00				$110.00
				7/31/06	Client	$10.00	$10.00				$100.00
				8/20/06	Aetna	$90.00	$90.00				$10.00
								8/20/06	Write-off	$10.00
	3/15/06	Client No-show	$100.00			$0.00	$0.00				$100.00
	2/2/06	90806	$100.00	2/2/06	Client	$20.00	$20.00				$80.00
				2/28/06	BC/BS	$30.00	$30.00				$50.00
				3/19/06	Aetna	$20.00	$20.00				$30.00
	1/20/06	90847	$120.00								$120.00
				2/15/06	Client	$10.00	$10.00				$110.00
				2/28/06	BC/BS	$0.00	$0.00				$110.00
				3/31/06	Client	$10.00	$10.00				$100.00
				4/20/06	Aetna	$90.00	$90.00				$10.00
				4/20/06	Write-off	$10.00	$10.00	4/20/06	Write-off	$10.00
	1/13/06	Client Late Cancel	$100.00			$0.00	$0.00				$100.00

Demographics

Personal Info

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

Contact Info

Cell Phone:
Home Phone:
Work Phone:
Other Phone:
Fax:
Email 1:
Email 2:

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

Insurance #1

Phones

Main:
Authorizations:
Fax:
Other:

Company Name:

Street Address:

Street Address 2:

City: State: Zip:

Provider ID:

Plan Type:

Notes:

Family Info

Appointments

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

Other

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

Norman Blake

Clients

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Transactions

Session

Payments & Adjustments

Balances