Start Date of Service:

End Date of Service:

Location Name:

10

Testing Site

CHECK-IN

90

ONSITE ACTIVATION

100

CHECKED-IN

5

MISSED

5

CANCELLED

SOAP NOTE

50

CLINICAL ASSESSMENT

100

SIGNED OFF

5

SUP-SIGNED OFF

RESULT DELIVERY

1000

KIT ASSIGNMENT

90

WAITING QUEUE

100

WAITING RESULTS

10

PENDING NOTIFICATIONS

35

FU SCHEDULED

31

RE-TEST

3125

NOT DETECTED

100

DETECTED

FOLLOW UP

50

FU SCHEDULED

100

FU MISSED

5

FU CANCELLED

5

FU SIGNED OFF

5

FU SUP-SIGNED OFF

Billing

90

READY TO BILL

100

MISSING INFORMATION

5

CLEAN & CLEAR

5

SUBMITTED CLAIMS

Your Information

First Name

Last Name

Date Of Birth

Address

Street

City

State

Zip

Contact Information

Phone Number SMS Notification

Email

Phone Type*

Custom Demo Fields

Gender*

Gender Indentity

Sexual Orientation

race*

Ethinicity*

Insurance

Insurance Provider

Insurance Member ID

Pverify Status

Insurance Group Number

Relationship to this insured

Insurance Int

Identification

Identification Type*

Identification Number

Identification Upload

Identification Type*

Identification Number

Identification Upload

Identification Type*

Identification Number

Identification Upload

Appt Date	DOS	Appt Status	Result Status	Billing Status
Appt Date	DOS	Appt Status	Result Status	Billing Status
10/22/2020	10/23/2020	Signed Off	Waiting Notification	Ready to Bill
10/22/2020	10/23/2020	Signed Off	Waiting Notification	Ready to Bill

Appointment Date	DOS	Collection Date	Payment type	Amount
Appointment Date	DOS	Collection Date	Payment type	Amount
10/10/2020	10/21/2020	10/10/2020	Authorize.net	$35.00
10/10/2020	10/21/2020	10/10/2020	Authorize.net	$35.00

PTID	First Name	Last Name	DOB	Phone	Street	City	State	Zip
PTID-1-1	Shakir	Ansari	10/10/1990	9173595860	Street	City	State	Zip

PTID	First Name	Last Name	DOB	Phone	Street	City	State	Zip
PTID	First Name	Last Name	DOB	phone	street	City	State	Zip
PTID-1-1	First Name	Last Name	DOB	Phone	Street	City	State	Zip
PTID-1-2	First Name	Last Name	DOB	Phone	Street	City	State	Zip