| Field | Value |
|---|---|
| Patient Name | WOODROW KIBBY |
| Date(s) of Service | 04/29/2026 |
| Claim Number | 33330 |
| Origin City | 8401 FOUNTAIN AVENUE WEST HOLLYWOOD, CA 90069-2561 US |
| Destination | 116 Axis Loop Georgetown, TX 78628 US |
| Emergency? | Yes |
| Hospital Ordered? | Yes |
| Transport Type | BLS |
| Transport Context | ER → Hospital |
| PAYER TYPE | Medicare |
| DENIAL TYPE | Medical Necessity |
| ESCALATION LEVEL | First Appeal |
| Optional Flag | Include Interest Demand |
| Date of Birth | 456-26 |
Print Appeal | Edit Entry