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The placeholders in form templates are replaced by actual values on the form. The Estimate Patient Cost window is the data source for the fields on the form template. The following table lists the form template placeholders and their corresponding fields on the Estimate Patient Cost window.
| Pre-Service Fields on the Form Template | Matching Field on the Estimate Patient Cost window |
|---|---|
| Pre-Service Appointment Date | Appt Date in the Patient/Guarantor Information section |
| Pre-Service Cost Estimate ID | Cost Estimate ID in the Patient/Guarantor Information section |
| Pre-Service Date of Service | Service Date in the History section |
| Pre-Service Diagnosis Code 1 to Pre-Service Diagnosis Code 12 | Diagnosis codes in the ICD-CM section |
| Pre-Service Encounter Date | EncNbr and Date in the Patient/Guarantor Information section |
| Pre-Service Encounter Number | EncNbr and Date in the Patient/Guarantor Information section |
| Pre-Service Estimate Date | Estimation Date/Time in the History section |
| Pre-Service Estimated Adjustment Amount | Estimated Adjustment in the Estimated Cost section |
| Pre-Service Estimated Allowed Amount | Estimated Allowed in the Estimated Cost section |
| Pre-Service Estimated Charge Amount | Estimated Charge in the Estimated Cost section |
| Pre-Service Estimated Coinsurance | Coinsurance in the Estimated Cost section |
| Pre-Service Estimated Copay | Copay in the Estimated Cost section |
| Pre-Service Estimated Deductible | Deductible in the Estimated Cost section |
| Pre-Service Estimated Min Amt to Request | Min Amt to Request in the Estimated Cost section |
| Pre-Service Estimated Non-Covered Amount | Non-Covered in the Estimated Cost section |
| Pre-Service Estimated Percentage to Request | Percentage to Request in the Estimated Cost section |
| Pre-Service Estimation Notes | Estimation Notes |
| Pre-Service Guarantor Address | Address of the guarantor in the Patient/Guarantor Information section |
| Pre-Service Guarantor City | Address of the guarantor in the Patient/Guarantor Information section |
| Pre-Service Guarantor Date of Birth | Date of Birth of the guarantor in the Patient/Guarantor Information section |
| Pre-Service Guarantor Name | Guar Name in the Patient/Guarantor Information section |
| Pre-Service Guarantor Relation | Relation in the Patient/Guarantor Information section |
| Pre-Service Guarantor State | Address of the guarantor in the Patient/Guarantor Information section |
| Pre-Service Guarantor Zip | Guar Address in the Patient/Guarantor Information section |
| Pre-Service Location Name | Patient Location in the Select Provider/Location/Service Type section |
| Pre-Service Patient Address | Patient Address in the Patient/Guarantor Information section |
| Pre-Service Patient City | Patient Address in the Patient/Guarantor Information section |
| Pre-Service Patient Date of Birth | Patient Date of Birth in the Patient/Guarantor Information section |
| Pre-Service Patient Name | Patient Name in the Patient/Guarantor Information section |
| Pre-Service Patient Paid Amount | Patient Paid Amt in the History section |
| Pre-Service Patient State | Patient Address in the Patient/Guarantor Information section |
| Pre-Service Patient Zip | Patient Address in the Patient/Guarantor Information section |
| Pre-Service Patient Payer Name/Self-Pay | Payer Selection |
| Pre-Service Provider Name | Provider in the Select Provider/Location/Service Type section |
| Pre-Service Service Type | Service Type in the Select Provider/Location/Service Type section |
| Pre-Service Patient Agrees to Pay | Patient Agrees to Pay |
| Pre-Service Total Ins Est Amount | Total Ins Est Amt in the Estimated Cost section |
| Pre-Service Total Pat Est Amount | Total Pat Est Amtin the Estimated Cost section |
| Pre-Service Charge 01 to Pre-Service Charge 25 | Up to 25 service line items sequentially in the Service Items table |
| Upon expanding a Pre-Service Charge item, the following placeholders pertaining to each service item are displayed. | |
| Pre-Service Chrg Adjustment Amount | Adj Amt of the service item |
| Pre-Service Chrg Allowed Amount | Allowed Amt of the service item |
| Pre-Service Chrg Charge Amount | Charge Amt of the service item |
| Pre-Service Chrg Coinsurance | Coins of the service item |
| Pre-Service Chrg Copay | Copay of the service item |
| Pre-Service Chrg CPT Code | CPT Code of service item |
| Pre-Service Chrg CPT Description | Description of the service item |
| Pre-Service Chrg Deductible | Deductible of the service item |
| Pre-Service Chrg Facility Price | Facility of the service item |
| Pre-Service Chrg Modifier 1 | M1 of the service item |
| Pre-Service Chrg Modifier 2 | M2 of the service item |
| Pre-Service Chrg Modifier 3 | M3 of the service item |
| Pre-Service Chrg Modifier 4 | M4 of the service item |
| Pre-Service Chrg Non-Covered Service | Non-Covered of the service item |
| Pre-Service Chrg Service Item | Svc Item of the service item |
| Pre-Service Chrg Unit(s) | Unit(s) of the service item |