Hs 210 Patient Ledger Assignment

Page 1of 3For this assignment, you will be completing an outpatient referral form for Jessica Smith (SS# 999-88-7777). Jessica is being referred by Dr. Hector Jones for a stat outpatient endoscopy procedure at Mercy Hospital with Dr. Robert Hughes. Jessica’s diagnosis is acute peptic ulcer for an unspecified site (ICD9-533.0). Jessica is insured with BlueCross/BlueShield and her dateof birth is 01/01/1970. Dr. Jones has requested that Jessica’s treatment notes be included with the referral form along with a copy of her insurance card. Dr .Jones has also requested that Jessica be contacted at 608-555-1212 when the referral form is ready for pick up.Blackburn Primary CareAssociates, P.C2500 Blackburn, Wisconsin Madison 12345Phone: 608-222-9797Fax: 608-222-9898Patient Referral FormPatient Name: Jessica Smith Phone # (608)505-1212SS# : 999-88-777 DOB: 01/01/1970Diagnosis: (ICD-9 Required) Acute Peptic Ulcer (ICD9-533.0)Insurance Type: BlueCross/BlueShield

Patient Daysheet/LedgerBlackburn Primary Care Associates1990 Turquoise DriveBlackburn, WI 12345(123) 456-7890 / (123) 456-7898Patient Name: Meagan Joy ReynoldsPatient Address: 5534 Joe Pool Lake Road #233City: Cedar HillState: TexasZip Code:75884Home Phone: 972-334-0423Cell Phone: 972-331-0934Email: [email protected]# REYM3341EntryDateReferenceServiceChargePaymentAdjustmentPrevious Balance112-Apr #7110Xray$375 $375 $0.00 221-AprSurgery$7,500 $0.00 $0.00 330-Apr #7261Follow-up$150 $150 $7,500 42-May617761 Payment$0.00 $6,200 $7,500 53-May #7317Payent$0.00 $300 $1,300 614-May #7512Office Visit $75 $50 $1,000 727-May #8710Payment$0 $800 $1,025 82-Jun #7915Payment$0 $125 $225 917-Jun #8116Office Visit/L$325 $150 $100 1020-Jun #8411Payment$0 $100 $302 1126-Jun #8626Office Visit $85 $50 $202 1230-JunFollow-up$85 $0 $237 135-Jul #7211146Payment$0 $276 $322 1422-Jul #7915NSF$0.00 $125 $46 1522-OctSent to Colle$0.00 $0 $171 1612-Dec #546Payment from$0.00 $0 $141 $171 1712-DecSmith Collect$0.00 $0.00 $30

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