CaptureBills - NOVOHUB Provider

Capture Bill

Filter:

Start Date

End Date

Full name	Policy Number	Visit Type	Date of Service	Verification Code	Follow-Up Code	Actions

Enrollee Details:

Full Name

Company

Subsidiary

Enrollee Age

Gender

Provider Details:

Encounter Type

Service Type

Doctor Details:

Name of Doctor

ID Number

Date Signed

Specialist Details (if any):

Name of Specialist

Specialist Phone No.

Area of Specialization

Date Signed

Treatment Details:

Verification Code

Follow-Up Code

Authorization Code (if any)

Date of Service

Date of Admission

Date of Discharge

Duration of Treatment

Referral Code

Treatment Given

Diagnosis

First Diagnosis

First Differential Diagnosis(Optional)

Second Diagnosis (Optional)

Second Differential Diagnosis(Optional)

Third Diagnosis (Optional)

Third Differential Diagnosis(Optional)

Service Details:

Select Service

Description

Duration

Amount

Total Amount

Services	Description	Duration	Price	Actions

Drug Details:

Select Drug

Description

Dosage

Amount

Total Amount

Drug	Description	Dosage	Price	Actions

Total Claims Details:

Total Amount