QuickView Info: A     QuickView Info: B

Patient Account #: 1234567
Place of Service: 22
Frequency: 1
Statement From/To: 01/01/2018 to 01/01/2018
Previous PDI/Claim ID: 123456789
Admission Type: UNK
Admission Source: UNK
Admission Date/Time: 01/01/2018     13:00
Accident Date: 01/01/2018
Patient Paid Amt: $999.99
Patient Signature: B
Patient Status: UNK
Prior Authorization: 123456789
Referral Number: 123456789
Provider Accept Asmt: A
Assignment of Benefits: Y
Discharge Date/Time: 01/01/2018     15:00
Accident Ind: 12 34 56
Pick-up Location
Address 1: 1234 Maple Street
Address 2: Apt. 303
City: Springfield
State: OH
ZIP Code: 12345
Drop-off Location
Address 1: 1234 Maple Street
Address 2: Apt. 303
City: Springfield
State: OH
ZIP Code: 12345
Transport Reason Code: Z
Transport Distance Miles: 200
Round Trip Purpose: Medical Care
Stretcher Purpose: Lorem ipsum dolor sit amet