| Field | Value |
|---|---|
| Patient Name | Artzen Juarez |
| Date of Birth | 4789-26 |
| Date(s) of Service | 04/16/2026 |
| Claim Number | 5555 |
| Origin City | Pres P Alojipan Street Centro Norte Pandan, Antique, CA 57120 US |
| Destination | 8401 FOUNTAIN AVENUE Centro Norte WEST HOLLYWOOD, CA 90069-2561 US |
| Emergency? | No |
| Hospital Ordered? | No |
| Transport Type | ALS |
| Transport Context | Hospital Discharge |
| PAYER TYPE | Medicare |
| DENIAL TYPE | No Claim on File |
| ESCALATION LEVEL | Second Appeal |
| Optional Flag | Urgent Review |
Print Appeal | Edit Entry