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Forms - Statements

Paper Form Pull Fields - Statements
Statements pull fields are to be used with the 'Statement' Form Type and will pull data onto paper form templates. Statements pull field categories include:

  • Account
  • Appointments
  • Custom Fields
  • Info
  • Items
  • Office
  • Patient Provider
  • Primary Referral
  • Provider
  • Secondary Referral
  • Tertiary Referral

 

 

Account

  • Account Balance 120 Days: This will display the total past due Account Balance for any charges that are between 121 and 150 days old as determined by the selected charge'(s) procedure date.
  • Account Balance 120 Plus Days: This will display the total past due Account Balance for any open charges that are over 120 days old as determined by the selected charge'(s) procedure date.
  • Account Balance 150 Plus Days: This will display the total past due Account Balance for any open charges that are over 150 days old as determined by the selected charge'(s) procedure date.
  • Account Balance 30 Days: This will display the total past due Account Balance for any open charges that are between 31 and 60 days old as determined by the selected charge'(s) procedure date.
  • Account Balance 60 Days: This will display the total past due Account Balance for any open charges that are between 61 and 90 days old as determined by the selected charge'(s) procedure date.
  • Account Balance 90 Days: This will display the total past due Account Balance for any open charges that are between 91 and 120 days old as determined by the selected charge'(s) procedure date.
  • Account Balance Current: This will display the total Account Balance for any open charges that are between 1 and 30 days old as determined by the selected charge'(s) procedure date.
  • Account Balance Days Overdue: This will display the age of the oldest open charge on the account.
  • Account Balance Insurance Portion: This will display the full balance for the account's Insurance Portion.
  • Account Balance Patient Portion: This will display the full balance for the account's Patient Portion.
  • Account Balance Total: This will display the total Account Balance (Insurance + Patient Portions).
  • Account Balance Total With Credit: This will display the total Account Balance less the Unapplied amount.
    [Note: This total will display as a negative if the credit balance is greater than the total account balance.]
  • Account Patient - Unapplied: This will display the total Patient Portion less the Unapplied amount.
    [Note: This total will display as a negative if the Unapplied amount is greater than the total Patient Portion.]
  • Account Patient Portion 120 Days: This will display the total past due Patient Portion balance for any open charges that are between 121 and 150 days old as determined by the selected charge'(s) procedure date.
  • Account Patient Portion 120 Plus Days: This will display the total past due Patient Portion balance for any open charges that are over 120 days old as determined by the selected charge'(s) procedure date.
  • Account Patient Portion 150 Plus Days: This will display the total past due Patient Portion balance for any open charges that are over 150 days old as determined by the selected charge'(s) procedure date.
  • Account Patient Portion 30 Days: This will display the total past due Patient Portion balance for any open charges that are between 31 and 60 days old as determined by the selected charge'(s) procedure date.
  • Account Patient Portion 60 Days: This will display the total past due Patient Portion balance for any open charges that are between 61 and 90 days old as determined by the selected charge'(s) procedure date.
  • Account Patient Portion 90 Days: This will display the total past due Patient Portion balance for any open charges that are between 91 and 120 days old as determined by the selected charge'(s) procedure date.
  • Account Patient Portion Current: This will display to total Patient Portion balance for any open charges between 1 and 30 days old as determined by the selected charge'(s) procedure date.
  • Account Patient Portion Total: This will display the total Patient Portion balance.
  • Account Unapplied Amount: This will display the account's total Unapplied amount.
  • Accounting Alert 1: This will display the first Alert record listed in Patients > Account > Alerts. This data will pull from the 'Alert Description' field located in the selected alert's Reference.
  • Accounting Alert 2: This will display the second Alert record listed in Patients > Account > Alerts. This data will pull from the 'Alert Description' field located in the selected alert's Reference.
  • Accounting Alert 3: This will display the third Alert record listed in Patients > Account > Alerts. This data will pull from the 'Alert Description' field located in the selected alert's Reference.
  • Accounting Alert 4: This will display the fourth Alert record listed in Patients > Account > Alerts. This data will pull from the 'Alert Description' field located in the selected alert's Reference.
  • Accounting Alert 5: This will display the fifth Alert record listed in Patients > Account > Alerts. This data will pull from the 'Alert Description' field located in the selected alert's Reference.
  • Accounting Alert 6: This will display the sixth Alert record listed in Patients > Account > Alerts. This data will pull from the 'Alert Description' field located in the selected alert's Reference.
  • Accounting Alert 7: This will display the seventh Alert record listed in Patients > Account > Alerts. This data will pull from the 'Alert Description' field located in the selected alert's Reference.
  • Accounting Alert 8: This will display the eighth Alert record listed in Patients > Account > Alerts. This data will pull from the 'Alert Description' field located in the selected alert's Reference.
  • City: This will reflect the data as entered in the 'City' field located in Patients > Primary.
  • Country: This will reflect the data as entered in 'Country' field located in Patients > Primary.
  • Date of Birth: This will reflect the date as entered in the 'Birth Date' field located in Patients > Primary.
  • Employer Address: This will display the Street Address of the first Employer record entered in the Employers table located in Patients > Primary. This data will pull from the 'Street Address' field located in the selected employer's Reference.
    [Note: If the Primary Guarantor does not have an employer entered in the Employers table this will then pull from the first Employer record entered in the Employers table located in Patients > Secondary.]
  • Employer City: This will display the City of the first Employer record entered in the Employers table located in Patients > Primary. This data will pull from the 'City' filed located in the selected employer's Reference.
    [Note: If the Primary Guarantor does not have an employer entered in the Employers table this will then pull from the first Employer record entered in the Employers table located in Patients > Secondary.]
  • Employer Name: This will display the Name of the first Employer record entered in the Employers table located in Patients > Primary. This data will pull from the 'Employer Name' filed located in the selected employer's Reference.
    [Note: If the Primary Guarantor does not have an employer entered in the Employers table this will then pull from the first Employer record entered in the Employers table located in Patients > Secondary.]
  • Employer State: This will display the State of the first Employer record entered in the Employers table located in Patients > Primary. This data will pull from the 'State' filed located in the selected employer's Reference.
    [Note: If the Primary Guarantor does not have an employer entered in the Employers table this will then pull from the first Employer record entered in the Employers table located in Patients > Secondary.]
  • Employer Suite: This will display the Suite number of the first Employer record entered in the Employers table located in Patients > Primary. This data will pull from the 'Suite' filed located in the selected employer's Reference.
    [Note: If the Primary Guarantor does not have an employer entered in the Employers table this will then pull from the first Employer record entered in the Employers table located in Patients > Secondary.]
  • Employer Zip Code: This will display the Zip Code of the first Employer record entered in the Employers table located in Patients > Primary. This data will pull from the 'Zip Code' filed located in the selected employer's Reference.
    [Note: If the Primary Guarantor does not have an employer entered in the Employers table this will then pull from the first Employer record entered in the Employers table located in Patients > Secondary.]
  • Financial Status: This will reflect the account's Financial Status as entered/selected from the 'Financial Status' drop down field located in Patients > Account.
  • Home Phone: This will reflect the data as entered in a 'Phone' field located in Patients > Primary.
    [Note: The 'Phone' field's adjoining 'Type' popup MUST be set to "Home Phone".]
  • Installment Amount: This will reflect the data as entered in the 'Installment Amount' field located in Patients > Account > Statements.
  • Installment or Balance Amount: This will reflect either the Account Balance or the Installment Amount as entered in the Account tab, depending on which is less.  When displaying the account balance the unapplied amount will be taken into account.
    [Note: this total will display as a negative if the credit balance is greater than the total account balance.]
  • Last Account Payment Amount (No Adj): This will display the amount of the most recent patient payment that has been posted the the Ledger.
  • Last Account Payment Amount (w/ Adj): This will display the most recent patient payment or negative adjustment that has been posted to the Ledger.
  • Last Account Payment Date (No Adj): This will display the date of the most recent patient payment that has been posted to the Ledger.
  • Last Account Payment Date (w/ Adj): This will display the date of the most recent patient payment or negative adjustment that has been posted to the Ledger.
  • Last Insurance Payment Amount: This will display the amount of the most recent insurance payment that has been posted to the Ledger.
  • Last Insurance Payment Date: This will display the date of the most recent insurance payment that has been posted to the Ledger.
  • Mobile Phone: This will reflect the data as entered in a 'Phone' field located in Patients > Primary.
    [Note: The 'Phone' field's adjoining 'Type' popup MUST be set to "Mobile Phone".]
  • Name: This will display the Full Name of the Primary Guarantor. This data will pull from the 'First Name', 'Middle Name', and 'Last Name' fields located in Patients > Primary.
    [Note: This pull field will display the data as "first name, middle initial, last name (John X. Doe).]
  • Name, First: This will display the First Name of the Primary Guarantor. This data will pull from the 'First Name' field located in Patients > Primary.
  • Name, Last: This will display the Last Name of the Primary Guarantor. This data will pull from the 'Last Name (Guarantor)' field located in Patients > Primary.
  • Name, Middle: This will display the Middle Name of the Primary Guarantor. This data will pull from the 'Middle Name' field located in Patients > Primary.
  • Name, Prefix: This will display the Prefix of the Primary Guarantor. This data will pull from the 'Prefix' field located in Patients > Primary.
  • Name, Suffix: This will display the Suffix of the Primary Guarantor. This data will pull from the 'Suffix' field located in Patients > Primary.
  • Other Phone: This will reflect the data as entered in a 'Phone' field located in Patients > Primary.
    [Note: The 'Phone' field's adjoining 'Type' popup MUST be set to "Other Phone".]
  • Percent Discount: This will reflect the data as entered in the 'Percent Discount (%)' field located in Patients > Account.
  • Previous Account Number: This will reflect the data as entered in the 'Previous Account Number' field located in Patients > Account.
  • SSN: This will reflect the data as entered in the 'Social Security' field located in Patients > Primary.
  • SSN Last 4: This will reflect the last four digits of the Social Security Number as entered in the 'Social Security' field located in Patients > Primary.
  • State: This will reflect the data as entered in the 'State' field located in Patients > Primary.
  • Street Address: This will reflect the data as entered in the 'Street Address' field located in Patients > Primary.
  • Suite: This will reflect the data as entered in 'Suite/Apt. Number' field located in Patients > Primary.
  • Work Phone: This will reflect the data as entered in a 'Phone' field located in Patients > Primary.
    [Note: The 'Phone' field's adjoining 'Type' popup MUST be set to "Work Phone".]
  • Zip Code: This will reflect the data as entered in the 'Zip Code' field located in Patients > Primary.

 

Appointments
Number of Appointments to display and row offset determined by Form Rules.
[Note: Default Form Rules: Max Appointments - 3; Row Offset - 15.00]

  • Appointment End: This will display either the Appointment Date or the Appointment End Time as determined by the patient's scheduled appointments.
    [Note: Functionality dependent upon pull field formatting ("Date" or "Time").]

  • Appointment Note: This will reflect the data as entered in the 'Notes' field found in the Appointment Detail Window of the patient's scheduled appointments.
  • Appointment Provider First Name: This will display the First Name of the provider as selected from the 'Provider' popup found in the Appointment Detail Window of the patient's scheduled appointments. This data will pull from the 'First' field located in the selected provider's User Reference.
  • Appointment Provider Last Name: This will display the Last Name of the provider as selected from the 'Provider' popup found in the Appointment Detail Window of the patient's scheduled appointments. This data will pull from the 'Last' field located in the selected provider's User Reference.
  • Appointment Provider Form Name: This will display the Form Name data for the provider as selected from the 'Provider' popup found in the Appointment Detail Window of the patient's scheduled appointments. This data will pull from the 'Name Printed in Box 33 HCFA' (DDS: 'Name Printed in Box 53 of Insurance Form') field located in the selected provider's User Reference > Provider.
  • Appointment Provider Middle Name: This will display the Middle Name of the provider as selected from the 'Provider' popup found in the Appointment Detail Window of the patient's scheduled appointments. This data will pull from the 'Middle' field located the selected provider's User Reference.
  • Appointment Provider Professional Title: This will display the Professional Title of the provider as selected from the 'Provider' popup found in the Appointment Detail Window of the patient's scheduled appointments. This data will pull from the 'Professional Title' field located the selected provider's User Reference.
  • Appointment Provider Suffix: This will display the Suffix of the provider as selected from the 'Provider' popup found in the Appointment Detail Window of the patient's scheduled appointments. This data will pull from the 'Suffix' field located the selected provider's User Reference.
  • Appointment Provider User ID: This will display the User ID of the provider as selected from the 'Provider' popup found in the Appointment Detail Window of the patient's scheduled appointments. This data will pull from the 'User ID' field located the selected provider's User Reference.
  • Appointment Resource Name: This will display the Resource Name for the patient's scheduled appointments. This data will pull from the 'Name' field found in the resource Reference for the appointments scheduled under the selected resource located in the Schedule.
  • Appointment Start: This will display either the Appointment Date or the Appointment Start time as determined by the patient's scheduled appointments.
    [Note: Functionality dependent upon pull field formatting ("Date" or "Time").]
  • Appointment Status: This will reflect the Appointment Status as entered/selected from the 'Status' dropdown found in the Appointment Detail Window of the patient's scheduled appointments.
  • Appointment Type: This will reflect the Appointment Type as entered/selected from the 'Type' dropdown found in the Appointment Detail Window of the patient's scheduled appointments.

 

Custom Fields

  • Custom Optional: This field will allow the User to manually type data directly onto a paper form when attempting to print said form. This field can be ignored and the form will print without data.
  • Custom Required: This field will allow the User to manually type data directly onto a paper form when attempting to print said form. This field cannot be ignored and MUST contain data before the form will be allowed to print.

Info

  • Account Balance: This will display the total Account Balance (Insurance + Patient Portions).
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