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Electronic Transmission Response Record (516) (2) (516) ) ——_— CLONAZEPAM 0.5MG TAB TRANSMISSION DATE/TIME: 06/05/18 15:52 PLAN CODE: | DE: __—_—£,,£e Fee Billed! 5.00 Ingredient Cost Billed: 19. Fee Paid: 0.00 Ingredient Cost Paid: 5 i Dai 53° other Insurance Paid: 0. Patient Pay: 5 RX Cost Profit/Loss: 4 “*PATIENT INSURANCE INFO** CROP: TT NETWORK: NE *+PArIENT 1 FIRST NAVE: GMM ase Ne: QL Addl. Message: UNDER MAX POCKET **PATIENT RESPONSIBILITY** copay: 5.76 LABEL WILL WOT PRINT FOR THIS CLAIM! REVERSE/RESUBMIT CLAIM WITH CORRECT INFO OR PRINT LABEL MANUALLY TO OVERRIDE 227 123 +00 76 Sx $M REL 00 i Total Paid: 223 Electronic Transmission Response Record 8) (16) AMLODIPINE TAB SMG Re | MM Re, 00 TRANSMISSION DATE/TIME: 05/15/18. 12207 PLAN CODE: =! ih: hy—i———_— Fee Billied: 5.00 Ingredient Cost Billed? 155.65 ee Paid: 0.00 Ingredient Cost Paids 130 Other Tneurence Paid: 0:00 Patient Pay 10162 total Pai 1.30 ie Cost Tes0. Profit/Loss 0:00 s+PAPTENT TNSURANCE.TNFO** 200 ‘ennon: Ne sspantewn anor og wT | Addi. Message: FOR QUESTIONS, CALL CIGNA 800- a SDRDUCTIBLE, INFORAATION™= REMAINING DEDUCTIBLES 1115.26 ear **PATIENT RESPONSIBILITY** DEDUCTIBLE: 10.62 LABEL WILL NOT PRINT FOR THIS CLAIM! REVERSE/RESUBMIT CLAIM WITH CORRECT INFO OR PRINT LABEL MANUALLY TO OVERRIDE, Electronic Transmission Response Record (sis) (6) ———e_ CIPROFLOXACN TAB 500MG Rx RPL 0 TRANSMESSTON DATE/TIME: 06/11/18 10229 Puan CODE! a a Fee Billed 5.00 Ingredient Goer Billed: 92.65 Feo Poids Ingredient Cost. Paid: 2.85 in nae mies 08 ent Pay 3100 Total Paid: 3.95 Protit/Less laa **PATTENT “INSURANCE _INFO** A? AE LETIORK: ET **PATIENT INFO** CM as — Addl. Message: UNDER MAX POCKE? **PATIENT RESPONSIBILITY** COPAY: 5.00 LABEL WILL NOT PRINT FOR THIS CLAIM! REVERSE/RESUBWIT CLAIM WITH CORRECT INFO OR PRINT LABEL MANUALLY TO OVERRIDE