| Field | Value |
|---|---|
| Patient Name | Francis Alojipan |
| Date of Birth | 1234-26 |
| Date(s) of Service | 04/21/2026 |
| Claim Number | 1 |
| Origin City | Pres P Alojipan Street Centro Norte Pandan, Antique, AL 5712_ US |
| Destination | Pres P Alojipan Street Centro Norte Pandan, Antique, CA 5712_ US |
| Emergency? | Yes |
| Hospital Ordered? | Yes |
| Transport Type | BLS |
| Transport Context | Hospital Discharge |
| PAYER TYPE | Medicare |
| DENIAL TYPE | Recoupment |
| ESCALATION LEVEL | First Appeal |
| Optional Flag | Include Interest Demand |
Print Appeal | Edit Entry