Cancelled Assignments

Use Standard Rate Interpretation Rate

Use Flat Rate

Use Standard Rate

Use Flat Rate

Standard Rate

Interp Rate

Flat Rate

The Standard Rate for this Trip is :

$ {{standardRateAndOtherCalculation.standardRateValue | number : 2}}

PO TOTAL	QTY
Live Miles
Dead Miles
Load Fee
Wait Time
Commercial Liability
Flat Rate

Extra Hour of Wait Time :

Late Cancellation :

No Show :

PO TOTAL	QTY	RATE	TOTAL
Live Miles
Dead Miles
Load Fee
Wait Time
Other Fee o1
Other Fee o1
Other Fee o1
Commercial Liability
Total

*Note : Considering Minimum Rate For Mileage

Extra Hour of Wait Time :

${{extraWaitTimePrice}}

Late Cancellation :

${{standardRateAndOtherCalculation.cancellationFee}}

No Show :

${{standardRateAndOtherCalculation.noShow}}

Estimated Client Bill Use Quote Rate Use flat rate for client bill
	PRODUCT ID	QTY	RATE	TOTAL
Live Miles
Rush Fee
Load Fee
Wait Time
{{pro.productName}}	1	{{pro.val}}
Total

Estimated Profit $
Estimated Profit %

Appointment Time:

Pickup Time:

Trip Details:

Pickup

Dropoff

Appointment Time:

Pickup Time:

Trip Details:

Pickup

Dropoff

PO TOTAL	QTY
Live Miles
Dead Miles
Load Fee
Interp Hours
Commercial Liability
Flat Rate

Extra Est. Interp Hours :

Late Cancellation :

No Show :

PO TOTAL	QTY	RATE	TOTAL
Live Miles
Dead Miles
Load Fee
Est. Interp Hours
Other Fee o1
Other Fee o1
Other Fee o1
Commercial Liability
Total

*Note : Considering Minimum Rate For Mileage

Late Cancellation :

${{standardRateAndOtherCalculation.cancellationFee}}

No Show :

${{standardRateAndOtherCalculation.noShow}}

Estimated Client Bill Use Quote Rate Use flat rate for client bill
	PRODUCT ID	QTY	RATE	TOTAL
Live Miles
Rush Fee
Load Fee
Wait Time
Interp Hours	Written
{{pro.productName}}	1	{{pro.val}}
Total

Estimated Profit $
Estimated Profit %

Appointment Time:

Pickup Time:

Trip Details:

Pickup

Dropoff

Appointment Time:

Pickup Time:

Trip Details:

Pickup

Dropoff

PO TOTAL	QTY	RATE
Est. Interp Hours	Est. Teleconference Interp	Est. Written Translation
PO TOTAL	QTY
$ Flat Rate
Travel Miles
Total

Late Cancellation :

No Show :

Estimated Client Bill Use Quote Rate Use flat rate for client bill
	PRODUCT ID	QTY	RATE	TOTAL
Interp Hours	Written
Travel Miles
Travel Time
{{pro.productName}}	1	{{pro.val}}
Total

Estimated Profit $
Estimated Profit %

Appointment Time:

{{currentBiddingAppointment.appointmentTime | date : 'HH.mm a' }}

({{appointmentDetail.pickUpInterpreterAddress.dropAddressName}}) {{appointmentDetail.pickUpInterpreterAddress.dropAddressLine1}} , {{appointmentDetail.pickUpInterpreterAddress.dropAddressLine2}} , {{appointmentDetail.pickUpInterpreterAddress.dropState}} , {{appointmentDetail.pickUpInterpreterAddress.dropCity}} , {{appointmentDetail.pickUpInterpreterAddress.dropZip}}

PO TOTAL	QTY	RATE
Est. Interp Hours	Est. Teleconference Interp	Est. Written Translation
Travel Miles
Travel Time
Total

Late Cancellation :

No Show :

Estimated Client Bill Use Quote Rate Use flat rate for client bill
	PRODUCT ID	QTY	RATE	TOTAL
Interp Hours	Written
Travel Miles
Travel Time
{{pro.productName}}	1	{{pro.val}}
Total

Estimated Profit $
Estimated Profit %

Appointment Time:

{{currentBiddingAppointment.appointmentTime | date : 'HH.mm a' }}

PO TOTAL	QTY
$ Flat Rate

Late Cancellation :

No Show :

Estimated Client Bill Use Quote Rate Use flat rate for client bill
	PRODUCT ID	QTY	RATE	TOTAL
Interp Hours	Written
Travel Miles
Travel Time
{{pro.productName}}	1	{{pro.val}}
Total

Estimated Profit $
Estimated Profit %

Appointment Time:

{{currentBiddingAppointment.appointmentTime | date : 'HH.mm a' }}

Interpreter Trip Distance

$ Travel Time Price Per Hour

$ Interpretation Price Per Mile

PO Remark *

Need help? Contact us at {{whiteLabel.phoneNumber | tel}} or {{whiteLabel.email}} .

Cancelled Assignments

View/Edit Appointment

Pending AVO QC List

DRAFT APPOINTMENT

Show Advanced Search Hide Advanced Search | Clear All

File No.

First Name

Middle Name

Last Name

Invoice Detail Available

Provider Name

FCM Name

Claim Number

Status

Sub Status

From Date

To Date

Date Type

Client

Adjuster Name

NCM Name

No appointments to show.

FILE NO.

DATE &
TIME

PATIENT
NAME

Client Name

PROVIDER

STATUS

Adjuster
Name

Case Manager
Name

Invoice Detail
Available

Unassigned (L)

Accepted (I) (TC) (W) Rejected (I) (TC) (W) Scheduled (I) (TC) (W) Started (I) (TC) (W) Completed (I) (TC) (W) ({{provider.appointmentFinishStatus}}) Invoiced (I) (TC) (W) ({{provider.appointmentFinishStatus}}) {{provider.status | camelCase}} (T, I) (I) (T) (L) (T, TC) (TC) (T) (T, W) (W) (T) ({{provider.appointmentFinishStatus}}) ({{provider.subStatus|camelCase}}) {{provider.status | camelCase}} ({{provider.cancelledBy}})

PO Sent (I) (TC) (W)

PO Created (I) (TC) (W)

Accepted (T) (L) (TC) Rejected (T) (L) (TC) Scheduled (T) (L) (TC) Started (T) (L) (TC) Completed (T) (L) (TC) ({{provider.appointmentFinishStatus}}) Invoiced (T) (L) (TC) ({{provider.appointmentFinishStatus}}) {{provider.status | camelCase}} (T, I) (I) (T) (L) (T, TC) (TC) (T) (T, W) (W) (T) ({{provider.appointmentFinishStatus}}) ({{provider.subStatus|camelCase}}) {{provider.status | camelCase}} ({{provider.cancelledBy}})

PO Sent (T) (L) (TC)

PO Created (T) (L) (TC)

{{getProviderStatus(provider) | camelCase}} {{provider.subStatus? ('('+provider.subStatus+')'):'' | camelCase}}

Accepted (T, I) (T, TC) (T,W) Scheduled (T, I) (T, TC) (T,W) Started (T, I) (T, TC) (T,W) Completed (T, I) (T, TC) (T,W) ({{provider.appointmentFinishStatus}}) Invoiced (T, I) (T, TC) (T,W) ({{provider.appointmentFinishStatus}}) {{provider.status | camelCase}} (T, I) (T, TC) (T,W) ({{provider.appointmentFinishStatus}}) ({{provider.subStatus|camelCase}}) {{provider.status | camelCase}} {{provider.cancelledBy?'('+provider.cancelledBy+')':''}}

PO Sent (T, I) (T, TC) (T,W)

PO Created (T, I) (T, TC) (T,W)

{{appointment.adjusterName}} NA

{{appointment.ncmName}} NA

Accepted (I) Rejected (I) Scheduled (I) Started (I) Completed (I) ({{provider.appointmentFinishStatus}}) Invoiced (I) ({{provider.appointmentFinishStatus}}) {{provider.status | camelCase}} (I) ({{provider.appointmentFinishStatus}}) ({{provider.subStatus|camelCase}}) {{provider.status | camelCase}} {{provider.cancelledBy?'('+provider.cancelledBy+')':''}}

PO Sent (I)

PO Created (I)

Accepted (T) Rejected (T) Scheduled (T) Started (T) Completed (T) ({{provider.appointmentFinishStatus}}) Invoiced (T) ({{provider.appointmentFinishStatus}}) {{provider.status | camelCase}} (T) ({{provider.appointmentFinishStatus}}) ({{provider.subStatus|camelCase}}) {{provider.status | camelCase}} {{provider.cancelledBy?'('+provider.cancelledBy+')':''}}

PO Sent (T)

PO Created (T)

{{getProviderStatus(provider) | camelCase}} {{provider.subStatus? ('('+provider.subStatus+')'):'' | camelCase}}

Accepted (T, I) Scheduled (T, I) Started (T, I) Completed (T, I) ({{provider.appointmentFinishStatus}}) Invoiced (T, I) ({{provider.appointmentFinishStatus}}) {{provider.status | camelCase}} (T, I) ({{provider.appointmentFinishStatus}}) ({{provider.subStatus|camelCase}}) {{provider.status | camelCase}} {{provider.cancelledBy?'('+provider.cancelledBy+')':''}}

PO Sent (T, I)

PO Created (T, I)

{{appointment.adjusterName}} NA

{{appointment.ncmName}} NA

Uber Portal App

AVO Inv N0. : {{appointment.providerDetails[0].companyInvoiceNumber ? appointment.providerDetails[0].companyInvoiceNumber : 'NA'}}

Vendor Inv N0. : {{appointment.providerDetails[0].invoiceNumber ? appointment.providerDetails[0].invoiceNumber : 'NA'}}

Vendor Tele No. : {{appointment.providerDetails[0].phone ? appointment.providerDetails[0].phone : 'NA'}}

Vendor Tax Id : {{appointment.providerDetails[0].taxId ? appointment.providerDetails[0].taxId : 'NA'}}

Vendor Status : {{appointment.transportAppointmentStatus ? appointment.transportAppointmentStatus : 'NA'}}

Claimant Rating : {{appointment.providerDetails[0].averageRatingWithPrecision ? appointment.providerDetails[0].averageRatingWithPrecision + ' Stars' : 'NA' }}

Claimant Comment : {{appointment.ratingRemark ? appointment.ratingRemark : 'NA'}}

Vendor Comment : {{appointment.providerDetails[0].bidRemark}}

FROW FROW

TRIP LOG

PICKUP ADDRESS

DROP ADDRESS

ROUND TRIP

MULTI LEG

File Number: {{v_fileNumber}}

	PO		Actual/Voucher		Client Invoice
	Qty	Amt	Qty	Amt	Qty	Amt
Live Miles	{{liveMilesProviderPODetail.poLineQty}}	{{liveMilesProviderPODetail.poLineExtendedDollar}}	{{liveMilesProviderVODetail.voucherLineQty}}	{{liveMilesProviderVODetail.voucherLineExtendedDollar}}	{{liveMilesClientInvoiceDetail.invoiceLineQty}}	{{liveMilesClientInvoiceDetail.invoiceLineTotal}}
Dead Miles	{{deadMileProviderPODetail.poLineQty}}	{{deadMileProviderPODetail.poLineExtendedDollar}}	{{deadMileProviderVODetail.voucherLineQty}}	{{deadMileProviderVODetail.voucherLineExtendedDollar}}	n/a	n/a
Wait Time	{{waitTimeProviderPODetail.poLineQty}}	{{waitTimeProviderPODetail.poLineExtendedDollar}}	{{waitTimeProviderVODetail.voucherLineQty}}	{{waitTimeProviderVODetail.voucherLineExtendedDollar}}	{{waitTimeClientInvoiceDetail.invoiceLineQty}}	{{waitTimeClientInvoiceDetail.invoiceLineTotal}}
Lift Fee	{{loadFeeProviderPODetail.poLineQty}}	{{loadFeeProviderPODetail.poLineExtendedDollar}}	{{loadFeeProviderVODetail.voucherLineQty}}	{{loadFeeProviderVODetail.voucherLineExtendedDollar}}	{{loadFeeClientInvoiceDetail.invoiceLineQty}}	{{loadFeeClientInvoiceDetail.invoiceLineTotal}}
Assisted Ambulatory Fee	n/a	n/a		n/a	n/a
Flat Rate	{{flatRateProviderPODetail.poLineQty}}	{{flatRateProviderPODetail.poLineExtendedDollar}}	{{flatRateProviderVODetail.voucherLineQty}}	{{flatRateProviderVODetail.voucherLineExtendedDollar}}	{{flatRateClientInvoiceDetail ? flatRateClientInvoiceDetail.invoiceLineQty : 'n/a'}}	{{flatRateClientInvoiceDetail ? flatRateClientInvoiceDetail.invoiceLineTotal : 'n/a'}}
Rush Fee					{{rushFeeClientInvoiceDetail.invoiceLineQty}}	{{rushFeeClientInvoiceDetail.invoiceLineTotal}}
Commercial Liability	{{commercialLiabilityProviderPODetail ? commercialLiabilityProviderPODetail.poLineQty : 'n/a'}}	{{commercialLiabilityProviderPODetail ? commercialLiabilityProviderPODetail.poLineExtendedDollar : 'n/a'}}		n/a	n/a	n/a
Additional Wait Time					n/a
Estimated Profit %	n/a	{{appointmentDetail.providers[0].estimatedProfitPercent}}	n/a	{{(appointmentDetail.providers[0] && appointmentDetail.providers[0].actualProfitRatio )? appointmentDetail.providers[0].actualProfitRatio : 'n/a' }}	n/a	n/a
Tolls/Parking	n/a	n/a	{{tollsOrParkingProviderVODetail ? tollsOrParkingProviderVODetail.voucherLineQty : 'n/a' }}	{{tollsOrParkingProviderVODetail ? tollsOrParkingProviderVODetail.voucherLineExtendedDollar : 'n/a'}}	{{tollsOrParkingProviderVODetail ? tollsOrParkingProviderVODetail.voucherLineQty : 'n/a' }}	{{tollsOrParkingProviderVODetail ? tollsOrParkingProviderVODetail.voucherLineExtendedDollar : 'n/a'}}
{{pro.productName}}					1

Total Amount		${{(poTotal).toFixed(2)}}		${{(voucherTotal).toFixed(2)}}
HES Discount						${{clientInvoiceData.hesDiscount}}
Net Payable						${{(hesReturnCost).toFixed(2)}}
HES Accepted Amount						${{(clientInvoiceData.hesResultCost).toFixed(2)}}

TRIP LOG

File Number: {{v_fileNumber}}

	PO		Actual/Voucher		Client Invoice
	Qty	Amt	Qty	Amt	Qty	Amt
Interpretation Time	{{interpreterHoursProviderPODetail.poLineQty}}	{{interpreterHoursProviderPODetail.poLineExtendedDollar}}	{{interpreterHoursProviderVODetail.voucherLineQty}}	{{interpreterHoursProviderVODetail.voucherLineExtendedDollar}}	{{interpreterHoursClientInvoiceDetail.invoiceLineQty}}	{{interpreterHoursClientInvoiceDetail.invoiceLineTotal}}
Travel Time	{{travelHourProviderPODetail.poLineQty}}	{{travelHourProviderPODetail.poLineExtendedDollar}}	{{travelHourProviderVODetail.voucherLineQty}}	{{travelHourProviderVODetail.voucherLineExtendedDollar}}	{{travelHourClientInvoiceDetail.invoiceLineQty}}	{{travelHourClientInvoiceDetail.invoiceLineTotal}}
Travel Mile	{{travelMileProviderPODetail.poLineQty}}	{{travelMileProviderPODetail.poLineExtendedDollar}}	{{travelMileProviderVODetail.voucherLineQty}}	{{travelMileProviderVODetail.voucherLineExtendedDollar}}	{{travelMileClientInvoiceDetail.invoiceLineQty}}	{{travelMileClientInvoiceDetail.invoiceLineTotal}}
Flat Rate	{{flatRateProviderPODetail.poLineQty}}	{{flatRateProviderPODetail.poLineExtendedDollar}}	{{flatRateProviderVODetail.voucherLineQty}}	{{flatRateProviderVODetail.voucherLineExtendedDollar}}	{{flatRateClientInvoiceDetail ? flatRateClientInvoiceDetail.invoiceLineQty : 'n/a'}}	{{flatRateClientInvoiceDetail ? flatRateClientInvoiceDetail.invoiceLineTotal : 'n/a'}}
{{pro.productName}}					1

Total Amount		${{(poTotal).toFixed(2)}}		${{(voucherTotal).toFixed(2)}}

{{}}

LODGING ADDRESS

AIRPORT ADDRESS

TRIP LOG

PICKUP ADDRESS

DROP ADDRESS

ROUND TRIP

MULTI LEG

File Number: {{v_fileNumber}}

	PO		Actual/Voucher		Client Invoice
	Qty	Amt	Qty	Amt	Qty	Amt
Flat Rate	{{flatRateProviderPODetail.poLineQty}}	{{flatRateProviderPODetail.poLineExtendedDollar}}	{{flatRateProviderVODetail.voucherLineQty}}	{{flatRateProviderVODetail.voucherLineExtendedDollar}}	{{lodgingClientInvoiceDetail.invoiceLineQty}}	{{lodgingClientInvoiceDetail.invoiceLineTotal}}
{{pro.productName}}					1

Total Amount		${{(poTotal).toFixed(2)}}		${{(voucherTotal).toFixed(2)}}
HES Discount						${{clientInvoiceData.hesDiscount}}
Net Payable						${{(hesReturnCost).toFixed(2)}}
HES Accepted Amount						${{(clientInvoiceData.hesResultCost).toFixed(2)}}

FROW FROW

TRIP LOG

PICKUP ADDRESS

DROP ADDRESS

ROUND TRIP

MULTI LEG

File Number: {{v_fileNumber}}

	PO		Actual/Voucher		Client Invoice
	Qty	Amt	Qty	Amt	Qty	Amt
Live Miles	{{liveMilesProviderPODetail.poLineQty}}	{{liveMilesProviderPODetail.poLineExtendedDollar}}	{{liveMilesProviderVODetail.voucherLineQty}}	{{liveMilesProviderVODetail.voucherLineExtendedDollar}}	{{liveMilesClientInvoiceDetail.invoiceLineQty}}	{{liveMilesClientInvoiceDetail.invoiceLineTotal}}
Dead Miles	{{deadMileProviderPODetail.poLineQty}}	{{deadMileProviderPODetail.poLineExtendedDollar}}	{{deadMileProviderVODetail.voucherLineQty}}	{{deadMileProviderVODetail.voucherLineExtendedDollar}}	n/a	n/a
Wait Time	{{waitTimeProviderPODetail.poLineQty}}	{{waitTimeProviderPODetail.poLineExtendedDollar}}	{{waitTimeProviderVODetail.voucherLineQty}}	{{waitTimeProviderVODetail.voucherLineExtendedDollar}}	{{waitTimeClientInvoiceDetail.invoiceLineQty}}	{{waitTimeClientInvoiceDetail.invoiceLineTotal}}
Lift Fee	{{loadFeeProviderPODetail.poLineQty}}	{{loadFeeProviderPODetail.poLineExtendedDollar}}	{{loadFeeProviderVODetail.voucherLineQty}}	{{loadFeeProviderVODetail.voucherLineExtendedDollar}}	{{loadFeeClientInvoiceDetail.invoiceLineQty}}	{{loadFeeClientInvoiceDetail.invoiceLineTotal}}
Assisted Ambulatory Fee	n/a	n/a	n/a	n/a	n/a	n/a
Rush Fee	n/a	n/a	n/a	n/a	{{rushFeeClientInvoiceDetail.invoiceLineQty}}	{{rushFeeClientInvoiceDetail.invoiceLineTotal}}
Commercial Liability	{{commercialLiabilityProviderPODetail ? commercialLiabilityProviderPODetail.poLineQty : 'n/a'}}	{{commercialLiabilityProviderPODetail ? commercialLiabilityProviderPODetail.poLineExtendedDollar : 'n/a'}}	n/a	n/a	n/a	n/a
Additional Wait Time	n/a	n/a	n/a	n/a	n/a	n/a
Interpretation Time	{{interpreterHoursProviderPODetail.poLineQty}}	{{interpreterHoursProviderPODetail.poLineExtendedDollar}}	{{interpreterHoursProviderVODetail.voucherLineQty}}	{{interpreterHoursProviderVODetail.voucherLineExtendedDollar}}	{{interpreterHoursClientInvoiceDetail.invoiceLineQty}}	{{interpreterHoursClientInvoiceDetail.invoiceLineTotal}}
Travel Time	{{travelHourProviderPODetail.poLineQty}}	{{travelHourProviderPODetail.poLineExtendedDollar}}	{{travelHourProviderVODetail.voucherLineQty}}	{{travelHourProviderVODetail.voucherLineExtendedDollar}}	{{travelHourClientInvoiceDetail.invoiceLineQty}}	{{travelHourClientInvoiceDetail.invoiceLineTotal}}
Travel Mile	{{travelMileProviderPODetail.poLineQty}}	{{travelMileProviderPODetail.poLineExtendedDollar}}	{{travelMileProviderVODetail.voucherLineQty}}	{{travelMileProviderVODetail.voucherLineExtendedDollar}}	{{travelMileClientInvoiceDetail.invoiceLineQty}}	{{travelMileClientInvoiceDetail.invoiceLineTotal}}
Flat Rate	{{flatRateProviderPODetail.poLineQty}}	{{flatRateProviderPODetail.poLineExtendedDollar}}	{{flatRateProviderVODetail.voucherLineQty}}	{{flatRateProviderVODetail.voucherLineExtendedDollar}}	{{flatRateClientInvoiceDetail ? flatRateClientInvoiceDetail.invoiceLineQty : 'n/a'}}	{{flatRateClientInvoiceDetail ? flatRateClientInvoiceDetail.invoiceLineTotal : 'n/a'}}
{{pro.productName}}					1

Total Amount		${{(poTotal).toFixed(2)}}		${{(voucherTotal).toFixed(2)}}

No appointments to show.

Once appointments are QC'd by AVO, they may be viewed and edited here.

FILE NO.

DATE & TIME

PATIENT NAME

IS RUSH ?

STATUS

Accepted (I) Rejected (I) Scheduled (I) Started (I) Completed (I) ({{provider.appointmentFinishStatus}}) Invoiced (I) ({{provider.appointmentFinishStatus}}) Invoiced (I) ({{provider.appointmentFinishStatus}}) {{provider.status | camelCase}} (I) {{provider.status | camelCase}} (I) ({{provider.appointmentFinishStatus}}) ({{provider.subStatus=="ESR"? provider.subStatus:(provider.subStatus|camelCase)}}) {{provider.status | camelCase}} ({{provider.cancelledBy}})

PO Sent (I)

PO Pending (I) PO Created (I)

Accepted (T) Rejected (T) Scheduled (T) Started (T) Completed (T) ({{provider.appointmentFinishStatus}}) Invoiced (T) ({{provider.appointmentFinishStatus}}) Invoiced (T) ({{provider.appointmentFinishStatus}}) {{provider.status | camelCase}} (T) {{provider.status | camelCase}} (T) ({{provider.appointmentFinishStatus}}) ({{provider.subStatus=="ESR"? provider.subStatus:(provider.subStatus|camelCase)}}) {{provider.status | camelCase}} ({{provider.cancelledBy}})

PO Sent (T)

PO Pending (T) PO Created (T)

Accepted (T, I) Scheduled (T, I) Started (T, I) Completed (T, I) ({{provider.appointmentFinishStatus}}) Invoiced (T, I) ({{provider.appointmentFinishStatus}}) Invoiced (T, I) ({{provider.appointmentFinishStatus}}) {{provider.status | camelCase}} (T, I) {{provider.status | camelCase}} (T, I) ({{provider.appointmentFinishStatus}}) ({{provider.subStatus=="ESR"? provider.subStatus:(provider.subStatus|camelCase)}}) {{provider.status | camelCase}} {{provider.cancelledBy?'('+provider.cancelledBy+')':''}}

PO Sent (T, I)

PO Pending (T,I) PO Created (T,I)

PO Sent (I)

PO Pending (I) PO Created (I)

PO Sent (T)

PO Pending (T) PO Created (T)

PO Sent (T, I)

PO Pending (T,I) PO Created (T,I)

You have reached the bottom of this page.

{{pro.productName}}

Credit Memo Number

: CM[invoice number]

Client:

client name

Email:

xyz321@gmail.com

Credit Memo Create Date

: 10/08/2020

Billing Address

: [billing address from client invoice]

Adjuster

: [Adjuster name from client invoice]

Claimant

: [Patient name from client invoice]

Claim

: [claim # from client invoice]

Credit Memo against Invoice

: [Client invoice #]

LINE ID	SERVICE DATE	SERVICE TYPE	DESCRIPTION	QTY	RATE	LINE TOTAL
1	NA	NA	NA	NA	NA	NA

Debit Memo Number

: DM[Voucher number]

Vendor

Vendor name

Email:

xyz321@gmail.com

Debit Memo Create Date

: 10/08/2020

Vendor Address

: [billing address from client invoice]

Claimant

: [Patient name from client invoice]

Debit Memo against Voucher

: [Voucher #]

LINE ID	SERVICE DATE	SERVICE TYPE	DESCRIPTION	QTY	RATE	LINE TOTAL
1	NA	NA	NA	NA	NA	NA