UPDATE #Request.prefix_db_lookup#.Agency SET Agency_Name = '#(form.Agency_Name)#', Agency_Address1 = '#Trim(form.Agency_Address1)#', Agency_City = '#Trim(form.Agency_City)#' , Agency_State = '#Trim(form.Agency_State)#', Agency_ZIP = '#Trim(form.Agency_ZIP)#', Agency_Contact_Phone = '#Trim(form.Agency_Contact_Phone)#', Agent_FEIN = '#Trim(form.Agent_FEIN)#', Natl_Provider_ID = '#Natl_Provider_ID#' WHERE Agency_ID = '#Session.AgencyID#' UPDATE #Request.prefix_db_agency#.pPatients SET Pt_Agy_ID = '#(form.agency_assigned_id)#', Pt_First = '#Trim(form.firstname)#', Pt_Last = '#Trim(form.lastname)#' , Pt_Street = '#Trim(form.Street_Address)#', Pt_City = '#Trim(form.City)#', Pt_State = '#Trim(form.State_M0050)#', Pt_Zip = '#Trim(form.Zip_M0060)#', Pt_DOB = #CreateODBCDate(form.DOB_M0066)#, Pt_Gender = '#Trim(form.gender)#' WHERE Patient_ID = '#Session.CS.PatientID#' UPDATE #Request.prefix_db_agency#.pAdmit SET M0030_START_CARE_DT = #CreateODBCDate(form.Start_of_care_M0030)#, Admission_Source = '#Trim(form.Source_of_Admission)#' WHERE Admit_ID = #form.Admit_ID# AND status = 0 UPDATE #Request.prefix_db_lookup#.pEmployee SET Emp_First = '#form.First_Name#', Emp_Last = '#form.Last_Name#' WHERE Emp_ID = #form.Emp_ID# UPDATE #Request.prefix_db_agency#.pAssessments SET F177 = #CreateODBCDate(form.Certification_Start)#, F178 = #CreateODBCDate(form.Certification_End)# WHERE Assmt_ID = '#form.ATID#' SELECT DISTINCT rc.Rev_Code,si.Visit_Type,rc.HCPCS,si.Visit_Date,si.Total_Units,si.Total_Eclaim ,si.Schedule_ID,i.Output AS Output_Type FROM #Request.prefix_db_agency#.Invoices i JOIN #Request.prefix_db_agency#.pSchedules si ON si.invoice_id = i.invoice_id RIGHT OUTER JOIN #Request.prefix_db_agency#.pRevenue_Code rc on rc.Rev_CodeID = si.Rev_ID WHERE i.invoice_id = '#url.inv#' AND i.Agency_ID = '#session.agencyid#' AND si.status = 0 UPDATE #Request.prefix_db_agency#.pSchedules SET Skill = '#form.Visit_Type#', Visit_Date = '#DateFormat(form.Visit_Date,"yyyy-mm-dd")#', Total_Units = '#form.Total_Units#', Total_Eclaim = '#form.Total_Eclaim#' WHERE Schedule_ID = '#GETSID.Schedule_ID#' UPDATE #Request.prefix_db_agency#.pSchedules SET Skill = '#VT#', Visit_Date = '#DateFormat(VD,"yyyy-mm-dd")#', Total_Units = '#TTU#', Total_Eclaim = '#TTE#' WHERE Schedule_ID = '#ID#' UPDATE #Request.prefix_db_lookup#.Supply_Sched SET Revenue_Code = '#Revenue_Code#', HCPCS = '#HCPCS#', Visit_Date = '#Visit_Date#', Total_Units = '#Total_Units#', Total_Price = '#Total_Price#' WHERE Supply_Sched_ID = '#Supply_Sched_ID#'
HEALTH INSURANCE UB04 CLAIM FORM

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