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Date

Doctor

Code

Description

Tendon

Place of Service

Primary ICD10

Secondary ICD10's

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External Cause Code

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Referring Doctor

Referring Doctor Practice Number

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Tariff

Qty

Unit Price

Total

Liable (P)

Liable (S)

Modifiers

Post Line

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Date	Inv-No	Code	Description	ICD10	Qty	Unit Fee	Patient	Scheme	Amount	Run. Bal	Edit	Delete

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Date

Doctor

Allocate To

Balance

Type

Method

Credit Card Cash Cheque Electronic Transfer Medical Aid Transfer

Amount

Date

Doctor

Allocate To

Method

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Amount

Procedure

Modifier

Time (In Minutes)

Assistant

Registration Number

Surname

Height (cm)

Weight (kg)

Modifier	Remove
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Claimables

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Invoice No	Date	Patient	Diagnosis	Procedures	Modifier	Liable(P)	Liable(S)	Amount	Include
	<%--GR included external Cause code --%> <%#DataBinder.Eval(Container, "DataItem.icd1")%> <%#DataBinder.Eval(Container, "DataItem.externalCause")%>: <%#DataBinder.Eval(Container, "DataItem.icdDescription")%>	<%#DataBinder.Eval(Container, "DataItem.patientName")%> <%#DataBinder.Eval(Container, "DataItem.patientSurname")%>	<%#DataBinder.Eval(Container, "DataItem.icd1")%>: <%#DataBinder.Eval(Container, "DataItem.icdDescription")%>	<%#DataBinder.Eval(Container, "DataItem.procedures")%>				<%----%>

Claim History

Transmission No		Switch Reference
Invoice No		Overall Result
Invoice Date		Responding Party
Diagnosis	<%--GR included external Cause code --%>	Delivery Type

Date Sent

Response Result

Responding Party

Delivery Type

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Procedure

Response Result

Responding Party

Delivery Type

Scheme Tracking No

Claimed Amount

Scheme Authorised

Patient Liable

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Claimed Amount	Discount Amount	Overcharged Amount	Patient Levy	MMAP Surcharge	Patient Co-Payment Amount	Patient Liable Portion	Medical Fund Liable Amount	Amount Authorised	Member Reimbursement Amount
<%#DataBinder.Eval(Container, "DataItem.treatmentClaimedAmount")%>	<%#DataBinder.Eval(Container, "DataItem.discountAmount")%>	<%#DataBinder.Eval(Container, "DataItem.overchargedAmount")%>	<%#DataBinder.Eval(Container, "DataItem.patientLevyAmount")%>	<%#DataBinder.Eval(Container, "DataItem.mmapSurcharge")%>	<%#DataBinder.Eval(Container, "DataItem.patientCoPaymentAmount")%>	<%#DataBinder.Eval(Container, "DataItem.patientLiableAmount")%>	<%#DataBinder.Eval(Container, "DataItem.medicalFundLiableAmount")%>	<%#DataBinder.Eval(Container, "DataItem.authAmountToProvider")%>	<%#DataBinder.Eval(Container, "DataItem.memberReimbursementAmount")%>

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Account Enquiry