360 Clinic | Admin Panel

Daily Payment Reports

Appointment ID	Patient ID	First Name	Last Name	Appointment Date	DOB	Collection Date	Collected By	Payment Type	Amount	Notes
Appointment ID	Patient ID	First Name	Last Name	Appointment Date	DOB	Collection Date	Collected By	Payment Type	Amount	Notes
APTID-1-1	PTID-1-2	Shakir	Ansari	11/2/2020	11/29/1986	11/4/2020	Ravi	Authorize.net	$35	Notes
APTID-1-2	PTID-1-3	Saimun	Hasan	11/2/2020	04/25/1994	11/4/2020	Kate	Cash	$30	Notes

Your Information

First Name

Last Name

Date Of Birth

Gender*

Address

Street

City

State

Zip

Contact Information

Phone Type*

Phone Number SMS Notification

Email

Custom Demo Fields

Gender Indentity

Sexual Orientation

race*

Ethinicity*

Primary Insurance

Primary Insurance Provider

Primary Insurance Member ID

Primary Pverify Status

Primary Insurance Group Number

Primary Relationship to this insured

Primary Insurance Int

Secondary Insurance

Secondary Insurance Provider

Secondary Insurance Member ID

Secondary Pverify Status

Secondary Insurance Group Number

Secondary Relationship to this insured

Secondary Insurance Int

Identification

Identification Type*

Identification Number

Identification Upload

Identification Type*

Identification Number

Identification Upload

Identification Type*

Identification Number

Identification Upload

Appt Date	DOS	Check In Status	Soap Status	Result Status	Follow up Status	Billing Status
Appt Date	DOS	Check In Status	Soap Status	Result Status	Follow up Status	Billing Status
10/22/2020	10/23/2020	Signed Off	Physical Exam	Waiting Notification	Follow Up Needed	Ready to Bill
10/22/2020	10/23/2020	Signed Off	Physical Exam	Waiting Notification	Follow Up Needed	Ready to Bill

Appointment Date	DOS	Collection Date	Payment Type	Amount
Appointment Date	DOS	Collection Date	Payment Type	Amount
Appointment Date	DOS	Collection Date	Payment Type	Amount

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