| Prompt |
Response |
Req |
Len |
| Note |
Type the alert message that you want
displayed when a patient account is selected. You can enter up
to 32,000 characters per record. |
|
60*4 |
| All Functions |
If you want this alert to display when
a patient is selected using Patient Look-up in all functions,
select this check box. |
|
1 |
| Patient |
If you want this alert to display when
a patient is selected in the Patient functions, select this check
box. |
|
1 |
| Limited Schedule |
If you want this alert to display when
a patient is selected using Patient Look-up in the Schedule functions,
select this check box. |
|
1 |
| Expanded Schedule |
If you want this alert to display when
a patient is selected using Patient Look-up in the Schedule functions,
select this check box. |
|
1 |
| Transactions |
If you want this alert to display when
a patient is selected using Patient Look-up in the Transactions
functions, select this check box. |
|
1 |
| Billing |
If you want this alert to display when
a patient is selected using Patient Look-up in the Billing functions,
select this check box. |
|
1 |
| Collections |
If you want this alert to display when
a patient is selected using Patient Look-up in the Collections
functions, select this check box. |
|
1 |
| Managed Care |
If you want this alert to display when
a patient is selected using Patient Look-up in the Managed Care
functions, select this check box. |
|
1 |
| Rx Management |
If you want this alert to display when
a patient is selected using Patient Look-up in the Rx Management
functions, select this check box. |
|
1 |
| System |
If you want this alert to display when
a patient is selected using Patient Look-up in the System functions,
select this check box. |
|
1 |
| Background Color |
Select the background color for the
alert message. Type the color code you want or click the magnifying
glass to select a color. |
|
10 |
| Text Style |
Select the text style for the alert
message from the Text Style list. |
|
1 |
| Text Underline |
Select this check box to underline the
alert message text. |
|
1 |
| Prompt |
Response |
Req |
Len |
| Contact Name |
Type the primary contact's first and
last name. |
|
35 |
| Address Line One |
Type the address for this contact. |
|
35 |
| Two |
Type any additional address information. |
|
35 |
| Zip Code |
Type the five digit zip code or the
zip-plus-four, including the dash, for this contact. |
|
10 |
| City |
Type the city for this contact. |
|
15 |
| State Code |
Select the state for this contact from
the State Code list. |
|
3 |
| Home Phone |
Type the phone number for this contact,
if different from the patient's. |
|
20 |
| Work Phone |
Type the work phone number for this
contact. |
|
20 |
| Cell Phone |
Type the cell or other phone number
for this contact. |
|
20 |
| Relationship |
Type the relationship of this contact
to the patient. |
|
35 |
| Secondary Contact |
Type the secondary contact's first and
last name. |
|
35 |
| Address Line One |
Type the address for this contact. |
|
35 |
| Address Line Two |
Type any additional address information. |
|
35 |
| Zip Code |
Type the five digit zip code or the
zip-plus-four, including the dash for this contact. |
|
10 |
| City |
Type the city for this contact. |
|
15 |
| State Code |
Select the state for this contact from
the State Code list. |
|
3 |
| Home Phone |
Type the phone number for this contact,
if different from the patient's. |
|
20 |
| Work Phone |
Type the work phone number for this
contact. |
|
20 |
| Cell Phone |
Type the cell or other phone number
for this contact. |
|
20 |
| Relationship |
Type the relationship of this contact
to the patient. |
|
35 |
Click Validate Address to convert
the address entered into the standard United States Postal Service format.
The Address Line One will be converted; the information in Address Line
Two (if standard) moves up to the end of Address Line One; the Zip Code
is converted to Zip+4 and the City and State are converted based on the
Zip Code. If a standard match cannot be found, messages display to explain.
If you disagree with the converted address, you can change it back and
save it without the validation changes. These changes will prevent claims
from being rejected or added to the Exception report due to an invalid
address or state code.
| Prompt |
Response |
Req |
Len |
| Family Members |
Type the number of individuals in this
family. |
 |
2 |
| Payroll Frequency |
Select the payroll frequency from the
Payroll Frequency list. |
|
1 |
| Payroll Amount$ |
Type the amount of each payroll. |
|
10 |
| Annual Income$ |
Type the annual income of the family.
This field will default with the annual income based on the amounts
you typed in the Payroll Frequency and Payroll Amount fields. |
|
10 |
| Review Date |
Type the date you want to review this
data or click the calendar icon to select a date. The Review Date
allows you to track which patients need to have their income reviewed.
This Review Date shows as an Alert on the patient's account thirty
days prior to the actual date entered. This alerts the clinic
if this patient makes an appointment or comes in for services.
Updated financial information can be obtained at that time. |
 |
10 |
| Migrant/Seasonal Program |
For UDS Reporting, select the Migrant/Seasonal
worker status option. |
|
1 |
| Homeless Program |
For UDS Reporting, select the homeless
status from the Homeless Program list. |
|
1 |
| Public Housing Program |
If this family is enrolled in a Public
Housing Program, select this check box. |
|
1 |
| School Based Program |
If this family is enrolled in a School
Based Program, select this check box. |
|
1 |
| Medical Fee $ |
Some clinics have minimum amounts they
want collected even if the family is at 100% poverty level. If
your practice varies its flat fees by family, type the flat fee
amount for medical services for this family, if applicable. (If
your practice charges the same flat fee for everyone, type the
flat fee in the Medical Fee $ field in the UDS Integration function
{Reports, UDS Reports}).
These fields also depend on how you chose to set up the order hierarchy
with the Nominal Fee $ field in the Type of Service Table and
in the Procedure Code Table at the time of installation. |
|
10 |
| Percentage |
After you save and go back into the
Family Income Data screen, this field defaults with the amount
stored in the Disc Percent field in Maintain Income Based Fees
(Tables, Fee Schedule Table), based on where the Annual Income$
falls within the Min Income and Max Income range. |
|
5 |
| Dental Fee $ |
Some clinics have minimum amounts they
want collected even if the family is at 100% poverty level. If
your practice varies its flat fees by family, type the flat fee
amount for dental services for this family, if applicable. (If
your practice charges the same flat fee for everyone, type the
flat fee in the Dental Fee $ field in the UDS Integration function
{Reports, UDS Reports}).
These fields also depend on how you chose to set up the order hierarchy
with the Nominal Fee $ field in the Type of Service Table and
in the Procedure Code Table at the time of installation. |
|
10 |
| Denied Discount |
If the patient's income is undeclared,
select this check box. |
|
1 |
| Veteran |
If a family member is a veteran, select
this check box. |
|
1 |
| Poverty Level |
If you want to force this patient into
a poverty level, A for highest level. |
|
1 |
| Prompt |
Response |
Req |
Len |
| Date Notice of Privacy Practices signed |
Type the date the patient signed this
document or click the calendar icon to select a date. |
|
10 |
| Date Disclosure of Health Info signed |
Type the date the patient signed this
document or click the calendar icon to select a date. |
|
10 |
| Exclusions/Alerts |
Type any additional information needed
regarding this patient pertaining to HIPAA regulations. If you
type anything in this field, the Alerts dialog box will display,
indicating the HIPAA Alert, each time you access the patient's
account. |
|
50*4 |
| PHI Release: Name |
Type the name of each individual the
patient has indicated to release/deny access to their Protected
Health Information (PHI). Up to 15 individuals can be entered. |
|
20 |
| Release/Deny: |
For each PHI Release name, select whether
to Release or Deny access for this individual. |
|
1 |
| Identifier: Mothers Maiden Name |
Type the maiden name of the patient's
mother. Every Identifier field is provided for you to capture
information that may be used to confirm your patient's identity
prior to disclosing their health information. |
|
15 |
| Identifier: City of Birth |
Type the patient's city of birth. |
|
15 |
| Identifier: Favorite Color |
Type the patient's favorite color. |
|
15 |
| Identifier: Optional |
Type any additional identifier text
applicable. |
|
15 |
| Identifier: Optional |
Type any additional identifier text
applicable. |
|
15 |
| Prompt |
Response |
Req |
Len |
| Date Admitted |
Type the date the patient was admitted
to the hospital or click the calendar icon to select a date. |
 |
10 |
| Date Discharged |
Type the date the patient was discharged
from the hospital or click the calendar icon to select a date. |
|
10 |
| Hospital |
Type the hospital location code or select
a code from the Hospital list. The only codes displayed in the
list are inpatient or outpatient location codes that contain an
equivalent location code of twenty-one (21), twenty-two (22),
thirty-one (31), fifty-one (51), or sixty-one (61) in the Location
Code Table. |
 |
5 |
| Floor # |
Type the hospital floor number assigned
to this patient. |
|
10 |
| Room # |
Type the hospital room number assigned
to this patient. |
|
10 |
| Reason for Admit |
Type the reason the patient was admitted
to the hospital. |
|
50*5 |
| MRN |
Type the Medical Record Number assigned
by the hospital for this patient. |
|
20 |
| Hospital Note |
Type any applicable hospital note text. |
|
50*5 |