Patient Account #: {{ billingMiscellanousData?.patientAccountNumber }} {{ billingMiscellanousData?.patientAccountNumber }}
{{ typeOfBillingOrFrequencyLabelString }} {{ billingMiscellanousData?.typeOfBill}} {{ billingMiscellanousData?.typeOfBill}} {{ billingMiscellanousData?.placeOfService }} {{ billingMiscellanousData?.placeOfService }} / {{ billingMiscellanousData?.frequency }} /{{ billingMiscellanousData?.frequency }}
Statement From/To: {{ billingMiscellanousData?.statementFromTo }} {{ billingMiscellanousData?.statementFromTo }}
Previous PDI/Claim ID: {{ billingMiscellanousData?.previousPDIOrClaimNumber }} {{ billingMiscellanousData?.previousPDIOrClaimNumber }}
Admission Type: {{ billingMiscellanousData?.admissionType }} {{ billingMiscellanousData?.admissionType }}
Admission Source: {{ billingMiscellanousData?.admissionSource }} {{ billingMiscellanousData?.admissionSource }}
Date/Hour: {{ billingMiscellanousData?.admissionDateOrHour }} {{ billingMiscellanousData?.admissionDateOrHour }}
Accident Date: {{ billingMiscellanousData?.accidentDate }} {{ billingMiscellanousData?.accidentDate }}
Accident Ind: {{ billingMiscellanousData?.accidentIndicator }} {{ billingMiscellanousData?.accidentIndicator }}
Patient Paid Amt: {{ billingMiscellanousData?.patientPaidAmount ==='\u2013\u2013\u2013' ? '\u2013\u2013\u2013' : '$'+ billingMiscellanousData?.patientPaidAmount }} {{ billingMiscellanousData?.patientPaidAmount ==='\u2013\u2013\u2013' ? '\u2013\u2013\u2013' : '$'+ billingMiscellanousData?.patientPaidAmount }}
Patient Signature: {{ billingMiscellanousData?.patientSignature }} {{ billingMiscellanousData?.patientSignature }}
Patient Status: {{ billingMiscellanousData?.patientStatus }} {{ billingMiscellanousData?.patientStatus }}
Prior Authorization: {{ billingMiscellanousData?.priorAuthorizationReferralLong }} {{ billingMiscellanousData?.priorAuthorizationReferralLong }}
Referral Number: {{ billingMiscellanousData?.referralLong_5010 }} {{ billingMiscellanousData?.referralLong_5010 }}
Provider Accept Asgmt: {{ billingMiscellanousData?.providerAcceptsAssignment }} {{ billingMiscellanousData?.providerAcceptsAssignment }}
Assignment of Benefits: {{ billingMiscellanousData?.assignmentOfBenefits }} {{ billingMiscellanousData?.assignmentOfBenefits }}
Discharge Date/Hour: {{ billingMiscellanousData?.dischargeDateOrHour }} {{ billingMiscellanousData?.dischargeDateOrHour }}
Medicare Int. Ctrl. Num: {{ billingMiscellanousData?.medicareIcn }} {{ billingMiscellanousData?.medicareIcn }}
Rendering Prov. Name: {{ billingMiscellanousData?.renderingPrvdName }} {{ billingMiscellanousData?.renderingPrvdName }}
NPI: {{ billingMiscellanousData?.renderingPrvdNpi }} {{ billingMiscellanousData?.renderingPrvdNpi }}
Taxonomy Code: {{ billingMiscellanousData?.renderingPrvdTaxonomyCode }} {{ billingMiscellanousData?.renderingPrvdTaxonomyCode }}
Diagnosis Related Grp: {{ diagnosisRelatedGroup }} {{ diagnosisRelatedGroup }}
DME Procedure: {{ billingMiscellanousData?.dmeProcedure }} {{ billingMiscellanousData?.dmeProcedure }}
DME Modifier: {{ billingMiscellanousData?.dmeModifier }} {{ billingMiscellanousData?.dmeModifier }}
DME Frequency: {{ billingMiscellanousData?.dmeFrequency }} {{ billingMiscellanousData?.dmeFrequency }}