360 Clinic | Admin Panel

Questionnaire

What country are you from?	USA
What are you symptoms	Fever
Rate Your experience	05 - Very Good
What are you symptoms	cough
Email	[email protected]
Phone	9153595860
Date of Service	01/20/2021

Physical Exam

What country are you from?	USA
What are you symptoms	Fever
Rate Your experience	05 - Very Good
What are you symptoms	cough
Email	[email protected]
Phone	9153595860
Date of Service	01/20/2021

Assessment

What country are you from?	USA
What are you symptoms	Fever
Rate Your experience	05 - Very Good
What are you symptoms	cough
Email	[email protected]
Phone	9153595860
Date of Service	01/20/2021

Place Of Care

What country are you from?	USA
What are you symptoms	Fever
Rate Your experience	05 - Very Good
What are you symptoms	cough
Email	[email protected]
Phone	9153595860
Date of Service	01/20/2021

01/05/2021
3:21 PM

01/05/2021
3:21 PM

01/05/2021
3:22 PM

CPT

Active CPT:

Active Modifiers:

ICD

Active ICD:

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

Authorize.net

Name On Card

Billing Zip

Charge Card

Credit Card Number

Expiration Date

CCV

Cash

Amount

Notes

Your Information

First Name

Last Name

Date Of Birth

Address

Street

City

State

Zip

Contact Information

Phone Number SMS Notification

Email

Phone Type*

Missing Information

Patient Type

Notify and Attach User

10/10/2020

10/10/2020

10/10/2020

Ready To Bill

Action	Labels	DOS	Soap Status	Appointment ID	Confirmation No	Patient	Payment	DX	CPT	Appointment
Action	Labels	DOS	Soap Status	Appointment ID	Confirmation No	Patient	Payment	DX	CPT	Appointment
SOAP Profile Merge Pt	New PT Covid HRSA	04/25/2020 < 30 Days	Sup Sign	APTID-1-1	X34G56	PTID-1-2 Shakir Ansari 11/29/1982	Authorize.net 254125874584 $45.00	DX	CPT	OC FAIR GROUND 10/25/2020 8:00 PM - 8:30 PM
SOAP Profile Merge Pt	Est. PT COVID Insured	04/25/2020 30 to 90 Days	Standing Order	APTID-1-2	TR45H4	PTID-1-1 Saimun Hasan 11/29/1998	P-Verify 22523366523 Valid	DX	CPT	OC FAIR GROUND 10/25/2020 8:00 PM - 8:30 PM
SOAP Profile Merge Pt	Est. PT Covid Undocumented	04/25/2020 >90 days	Clinical Assessment	APTID-1-2	TR45H4	PTID-1-2 Shakir Ansari 11/29/1982	P-Verify 22523366523 Valid	DX	CPT	OC FAIR GROUND 10/25/2020 8:00 PM - 8:30 PM

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