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Visit Date Patient Name Provider No Show/Non-Insurance Diagnosis CPT/Services Billing Note/Issue Note Complete In QB Claim Submitted Patient Paid Insurance Paid/Unpaid Discount/Funded/Closed
June 23, 2017 Clough, Stephen JLF / 1- 1-(1) / //
June 23, 2017 Hyland, Amanda JLF /Non-Insurance, NI 1- 1-90837(1)

payment $102 weekly

NC Yes, IQ Yes, PR / //
June 23, 2017 Walton, Shaniqua JLF / 1- 1-(1) / //
June 22, 2017 Stock, Bonnie JLF / 1- 1-90837(1) NC / //
June 22, 2017 Walter, Sophia JLF / 1-F419 Anxiety disorder, unspecified  1-90837(1) NC / //
June 22, 2017 malone, tabitha JLF / 1- 1-99198(1) NC / //
June 22, 2017 Scott, Trukessa JLF / 1-F4323 Adjustment disorder with mixed anxiety and depressed mood  1-90847(1) Issue:

6 of 10

NC / //
June 22, 2017 Kenney, Sherry JLF / 1-F4325 Adjustment disorder with mixed disturbance of emotions and conduct  1-90847(1) NC / //
June 22, 2017 speth, philp JLF / 1-F90.0 Attention-Deficit/Hyperactivity Disorder (Predominantly Inattentive presentation) 1-90847(1)

$25 copay

NC / //
June 22, 2017 Huggins, David JLF / 1-F419 Anxiety disorder, unspecified  1-90853(1)

25

NC / //
June 22, 2017 Hayes, Oscar JLF / 1-F419 Anxiety disorder, unspecified  1-90853(1)

$10 group fee as a mentor.

NC / //
June 22, 2017 Rice, Jerry JLF / 1- 1-90853(1)

? left on balance/$20 Copay

/ //
June 22, 2017 Whitaker, Torrey JLF / 1- 1-(1)

Paid final payment

NC / //
June 21, 2017 Cowan-Richardson, Nakiesha JLF / 1-F4325 Adjustment disorder with mixed disturbance of emotions and conduct  1-90846(1) NC IQ CS PR / //
June 21, 2017 speth, philp JLF / 1-F419 Anxiety disorder, unspecified  1-90837(1)

$25 copay

NC IQ CS PR / //
June 21, 2017 malone, tabitha JLF / 1-F4323 Adjustment disorder with mixed anxiety and depressed mood  1-99198(1) NC IQ PR / //
June 20, 2017 Buchheit, Gary JLF /NI 1-F419 Anxiety disorder, unspecified  1-90837(1)

4 of 12

NC IQ PR / //
June 20, 2017 Whitaker, Torrey JLF /NI 1- 1-(1)

Paid final payment

NC IQ PR / //
June 20, 2017 Cousin, Keyondra JLF / 1- 1-(1)

$25 copay

NC IQ CS PR / //
June 20, 2017 Nash-Stevenson, Shelia JLF / 1- 1-(1)

$129 ded paid. $52.50 per session due.

Need BCBS Gr#. No record of payment for 3/30/17.

NC IQ CS PR / //
June 20, 2017 Drain, Moneatha JLF / 1- 1-90853(1)

Copay $25

NC IQ CS PR / //
June 20, 2017 Overton, Lisa JLF /NI 1- 1-90853(1)

$75 copay; Don't bill insurance for group sessions.

NC IQ PR / //
June 19, 2017 Easter, Esther JLF / 1- 1-90837(1)

$40 paid

NC IQ CS PR / //
June 19, 2017 Murray, Cameron JLF /NI 1- 1-90791(1)

Paid package

NC IQ IR/ //
June 19, 2017 Scott, Trukessa JLF /NI 1- 1-(1)

Purchasing intimacy builder.

NC IQ IR/ //
June 19, 2017 Jones, Gregory JLF / 1- 1-90837(1)

$12 Copay/Call Tricare

NC IQ CS PR / //
June 16, 2017 Hyland, Amanda JLF No Show, NS/Non-Insurance, NI 1- 1-90837(1)

payment $102 weekly

NC Yes, IQ Yes, PR / //
June 15, 2017 McCain, Latosha JLF / 1- 1-(1)

$25 copay

NC IQ CS PR / //
June 15, 2017 Swoope, Deidre JLF /NI 1- 1-90837(1)

$500 b-weekly; 4/16 ind. sessions

NC IQ PR / //
June 15, 2017 Cousin, Keyondra JLF / 1- 1-(1)

$25 copay

NC IQ CS PR / //