Progress Report Overview

Student: Emma Strobach

Activity: New Patient Registration and Scheduling A

Start Time: 09/08/2021 21:24:27

End Time: 09/08/2021 21:48:18

Total Time: 00:23:50

Actions

Patient at 09/08/2021 21:32:33 Appointment at 09/08/2021 21:47:17

Insurance at 09/08/2021 21:42:05

New Patient Registration and Scheduling A
Documentation
Student: Emma Strobach
Activity Start: 09/08/2021 21:24:27
Activity Completion: 09/08/2021 21:48:18
Activity Completion: 00:23:50

Patient Data

Patient: Carla Delange DOB: 01/01/1980

Age/Sex: 41 yo F MR#: MR10045

Registration

Registration at 09/08/2021 21:32

Patient Information

First Name Carla

Last Name Delange

Middle Name or Initial Louise

Sex F

Date of Birth 01/01/1980

SSN 100-00-0001

Medical Record Number MR10045

Marital Status MA

Language English

Patient Race/Ethnicity BA

Cell Phone 617-111-2498

Street Address 445 Sycamore Avenue

City Boston

State/Province MA

ZIP/Postal Code 02130

Employment Status PS

Emergency Contact

First Name Frederick

Last Name Delange

Contact's Phone Number 617-048-1829

Street Address 445 Sycamore Avenue

City Boston

State/Province MA

ZIP/Postal Code 02130

Provider Information

Primary Care Provider Arturo Rubio, NP

Referring Provider Arturo Rubio, NP

Rendering Provider Padma Amil, MD

Service Location Central Clinic

Guarantor Information

Relationship SE

First Name Carla

Last Name Delange

Street Address 445 Sycamore Avenue

City Boston

State/Province MA

ZIP/Postal Code 02130

Insurance

Insurance
Insurance Information

Insurance Priority Primary

Active Y

Policy Holder SP

Type of Coverage GHP

Insurance Company BlueCross BlueShield

Member ID JZP1230983845

Plan Type PPO

Plan Name BCBS Family

Group Name MacDonald Industries

Group Number 1058742

Effective Date 01/01/2020

Expiration Date 12/31/2022

Policy Details Office Copay $30; ER Copay $0

Policy Holder's Information

First Name Frederick

Last Name Delange

Sex M

Date of Birth 02/01/1985

Employer MacDonald Industries

Street Address 445 Sycamore Avenue

City Boston

State/Province MA

ZIP/Postal Code 02130

Phone Number 617-048-1829

Scheduling

Clinic Schedule 09/15/2021 08:00

Appointment

Provider Amil MD

Location Central Clinic

Type of Appointment Mental Health

Duration 45

Status active

Confirmation Not Confirmed

Condition relates to None

NO-SHOW false