Invoice R-Report

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Print Collection Agency Report
From the main invoice screen (below) selecting R-Report print pertinent information about an invoice that can be used for a variety of reasons, one being turning over to a collection agency. Certain fields in the COMPANY screen determine just how much information is printed.

wpeE.jpg (46162 bytes)
Screen 1-Main Invoice
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06/23/93 YOUR COUNTY E.M.S. INC. Page 1

DETAIL REPORT FOR INVOICE: M1 -10002 PATIENT: MURPHYJO
INVOICE INFORMATION
------------------
Stat: C Service Date: 10/22/92 Due Date: 12/01/92 Service Type: E
Service Ordered By: 911 Purchase Order No: 911
Service Related To Employment: N
Accident: N Service Level: A Round Trip: N Return Veh: Transported From: SC test
Transported To: WGE WEST GA MEDICAL CTR - EMERG DEPT
Medicare Base Rate Modifier:SH Medicare Necessity Modifier:Medicare Information Code:

PATIENT INFORMATION
-------------------
Patient Code: MURPHYJO JOHN S MURPHY WGC 3/93
Contract Code: MURPHYJO
Contact:
Street: RT. 2, Phone: ( )
City: LAGRANGE , GA Zip: 30241
Race, W/B/O: W Sex, M/F: M Date of Birth: 12/11/63
Social Sec: 999-99-9999 Patient Status: A
Medicare: 1234 Medicaid: 256503282-P
Date Employment Verified: / / Employment Status: 1
Responsible for Payment, P/R: P
Responsible Party: JONNE K MURPHY WGC 3/93
Finance Charges, Y/N: N
NOT ELIGIBLE FOR MEDICAID IN OCTOBER 92
EMPLOYER INFORMATION
--------------------
Employer Code: SPEEDWRE Name: SPEEDWRENCH
Employer Status: A Phone: (706)
Street: WHITESVILLE RD
City: LAGRANGE , GA Zip: 30240
Insurance Company Code: UNK INSURANCE COMPANY UNKNOWN
Group Number:

DOCTOR INFORMATION
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Doctor Code: ER Name: EMERGENCY DEPT. PHYSICIAN
Status: A UPIN: OTH000 Phone: ( )
Specialty:
Street:
City: , Zip:

06/23/93 YOUR COUNTY E.M.S. INC. Page 2

DETAIL REPORT FOR INVOICE: M1 -10002 PATIENT: MURPHYJO
PRIMARY PAYCODE INFORMATION
---------------------------
Pri Pay Code: 1 Medicare Approval: Discount %
Reason For Transport: B Accept Assignment:Y Transported To/For: A
Paid/Rejected: R Reason: reasponen test
Service Ordered By Code: Sign. On File: Date Filed: 01/01/93
Physician's Statement On File: Modifier: Date Refiled: / / Condition/Diagnosis Code: Date Verified: / /
Procedure Code: Patient Status: Attendant:
EMT: Driver: Jimmy Blackstone
Pickup Time: : Start: 0: 0 Stop: 0: 0 Start: 0
SECONDARY PAYCODE INFORMATION
-----------------------------
Sec Pay Code: 9 Writeoff Physician's Statement On File:
Paid/Rejected: Reason:
Accept Assignment: Procedure Code: Date Filed: / /
Service Ordered By Code: Patient Status: Date Refiled: / /
Condition/Diagnosis Code: Date Verified: / /
Approval: Sign. On File: Carrier Code:
Pickup Time: : Start: 0 Start: 0: 0 Stop: 0: 0
Attendant Driver:
EMT:
PAYCODE 7 - MONTHLY PAY
-----------------------
Date Payment Arrangements Were Made: 01/01/93
Monthly Payment Amount: 10.00 Date Of Last Payment: 01/01/93
Note 1: note 1
Note 2:
TRANSACTION SUMMARY
-------------------
Date Invoice Charges Payments Description Balance
---------------------------------------------------------------------
10/22/92 M1 -10002 190.00 ALS BASE RATE 190.00
10/22/92 M1 -10002 3.00 ALS MILEAGE 193.00
01/01/93 M1 -10002 MEDICARE FILED 193.00
02/05/93 M1 -10002 0.00 SEC INS DENIED 193.00
03/19/93 M1 -10002 28.95 FINANCE CHARGE 221.95