Family medicine clinic
Birchcombe Commons Family Medicine · Family medicine clinic · Duluth, MN
Hollis Jablonski manages the practice at Birchcombe Commons Family Medicine, a Duluth primary care clinic with three clinicians, and she uses this to bill each visit, collect signed financial agreements and chase what patients still owe.
HealthcareBillingDocuments and e-sign5 tables · 8 views · 2 forms · 1 dimension set · 1 dashboard · 1 digest · 1 document · 1 notification · 1 stage rule set · 1 agent
Use this templateBilling board
Visit billsDraft3
VB-60152Evander Mkhize-HoltEstablished patient visit, brief
VB-60173Anneliese DragomirBlood draw
VB-60224Ignatius OkparaekeEstablished patient visit, standard
Sent7
VB-60116Wilhelmina Strandberg-OseiAnnual physical
VB-60125Casimir OdenkirkEstablished patient visit, brief
VB-60158Fenella HaverstockStrep test
VB-60164Lazlo PettiboneEstablished patient visit, brief
VB-60194Percival Nakagawa-DunnEstablished patient visit, brief
2 morePartly paid4
VB-60146Evander Mkhize-HoltEstablished patient visit, extended
VB-60149Evander Mkhize-HoltEstablished patient visit, standard
VB-60185Soledad Achebe-LindqvistEstablished patient visit, extended
VB-60200Olumide Brightmoor-ReyesBlood draw
Overdue8
VB-60119Casimir OdenkirkEstablished patient visit, standard
VB-60122Casimir OdenkirkStrep test
VB-60131Thandiwe Ellsworth-KerrEstablished patient visit, standard
VB-60134Bertrand LaghariEstablished patient visit, extended
VB-60137Bertrand LaghariBlood draw
3 morePaid18
VB-60110Wilhelmina Strandberg-OseiEstablished patient visit, standard
VB-60113Wilhelmina Strandberg-OseiFlu shot
VB-60128Thandiwe Ellsworth-KerrNew patient visit
VB-60140Ysolde Marchetti-KwanAnnual physical
VB-60143Ysolde Marchetti-KwanFlu shot
13 moreTables
Visit bills
40 sample rows · 16 columnsEach visit billed to a patient: the charge, what the insurer pays, what the patient has paid and what is left.
| Bill number | Patient | Service | Seen by | Visit date | Charge | Insurance portion |
|---|---|---|---|---|---|---|
| VB-60224 | Ignatius Okparaeke | Established patient visit, standard | Rosamund Achterholt | Oct 5, 2026 | $148 | $104 |
| VB-60173 | Anneliese Dragomir | Blood draw | Kwabena Linthicum | Oct 4, 2026 | $29 | $26 |
| VB-60152 | Evander Mkhize-Holt | Established patient visit, brief | Kwabena Linthicum | Oct 3, 2026 | $96 | $67 |
| VB-60212 | Leocadio Fairbairn-Osei | Flu shot | Kwabena Linthicum | Oct 1, 2026 | $42 | $38 |
| VB-60125 | Casimir Odenkirk | Established patient visit, brief | Kwabena Linthicum | Sep 30, 2026 | $96 | $67 |
| VB-60194 | Percival Nakagawa-Dunn | Established patient visit, brief | Kwabena Linthicum | Sep 28, 2026 | $96 | $77 |
| VB-60143 | Ysolde Marchetti-Kwan | Flu shot | Rosamund Achterholt | Sep 26, 2026 | $42 | $38 |
| VB-60116 | Wilhelmina Strandberg-Osei | Annual physical | Rosamund Achterholt | Sep 23, 2026 | $265 | $212 |
| VB-60158 | Fenella Haverstock | Strep test | Thaddeus Mbeki-Lund | Sep 20, 2026 | $38 | $34 |
| VB-60206 | Rosalind Verhoeven | Strep test | Rosamund Achterholt | Sep 17, 2026 | $38 | $34 |
| VB-60164 | Lazlo Pettibone | Established patient visit, brief | Rosamund Achterholt | Sep 15, 2026 | $96 | $0 |
| VB-60218 | Imogen Castellanos-Roy | Established patient visit, brief | Thaddeus Mbeki-Lund | Sep 13, 2026 | $96 | $72 |
28 more rows
Patients
18 sample rows · 9 columnsThe people the clinic sees, how they are covered and what they owe across their bills.
| Patient | Date of birth | Phone | Coverage | Member id | Patient status | |
|---|---|---|---|---|---|---|
| Anneliese Dragomir | Aug 19, 1965 | (218) 555-0109 | anneliese.dragomir@lakeheadpostalbox.net | Superior Health Alliance | SHA9013356 | Active |
| Bertrand Laghari | Jan 9, 1971 | (218) 555-0104 | bertrand.laghari@lakeheadpostalbox.net | Self-pay | — | Active |
| Casimir Odenkirk | Nov 2, 1983 | (218) 555-0102 | casimir.odenkirk@lakeheadpostalbox.net | Lakehead Mutual | LMU2290815 | Active |
| Cordelia Vasquez-Hale | Mar 6, 2004 | (218) 555-0118 | cordelia.vasquez@lakeheadpostalbox.net | Superior Health Alliance | SHA3321970 | Active |
| Evander Mkhize-Holt | Dec 21, 1949 | (218) 555-0106 | evander.mkhize@lakeheadpostalbox.net | Lakehead Mutual | LMU7710096 | Active |
| Fenella Haverstock | Mar 14, 1988 | (218) 555-0107 | fenella.haverstock@lakeheadpostalbox.net | Arrowhead Care Plan | ACP3350871 | Active |
| Ignatius Okparaeke | Jul 12, 1962 | (218) 555-0117 | ignatius.okparaeke@lakeheadpostalbox.net | Lakehead Mutual | LMU8837451 | Active |
| Imogen Castellanos-Roy | Jan 31, 1986 | (218) 555-0116 | imogen.castellanos@lakeheadpostalbox.net | Arrowhead Care Plan | ACP6639208 | Active |
| Jorund Whitcombe | Feb 11, 2008 | (218) 555-0110 | jorund.whitcombe@lakeheadpostalbox.net | Lakehead Mutual | LMU4458120 | Active |
| Lazlo Pettibone | Jun 5, 1976 | (218) 555-0108 | lazlo.pettibone@lakeheadpostalbox.net | Self-pay | — | Active |
| Leocadio Fairbairn-Osei | Apr 22, 1997 | (218) 555-0115 | leocadio.fairbairn@lakeheadpostalbox.net | Superior Health Alliance | SHA7045829 | Active |
| Olumide Brightmoor-Reyes | Dec 15, 1980 | (218) 555-0113 | olumide.brightmoor@lakeheadpostalbox.net | Self-pay | — | Active |
6 more rows
Financial agreements
10 sample rows · 13 columnsWhat each patient has agreed to about paying their share, with the bills raised under it.
| Agreement | Patient | Kind of agreement | Most paid in a month | Signature | Signed on | Covers visits from |
|---|---|---|---|---|---|---|
| Brightmoor-Reyes: self-pay terms | Olumide Brightmoor-Reyes | Self-pay terms | — | Sent | — | — |
| Castellanos-Roy: financial policy | Imogen Castellanos-Roy | Standard financial policy | — | Signed | Jul 30, 2026 | Aug 2, 2026 |
| Dragomir: financial policy | Anneliese Dragomir | Standard financial policy | — | Signed | Jul 7, 2026 | Jul 10, 2026 |
| Laghari: self-pay terms | Bertrand Laghari | Self-pay terms | — | Signed | Jul 19, 2026 | Jul 22, 2026 |
| Mkhize-Holt: installment terms | Evander Mkhize-Holt | Installment terms | $200 | Signed | Jul 21, 2026 | Jul 24, 2026 |
| Nakagawa-Dunn: financial policy | Percival Nakagawa-Dunn | Standard financial policy | — | Signed | Jul 25, 2026 | Jul 28, 2026 |
| Odenkirk: installment terms | Casimir Odenkirk | Installment terms | $250 | Signed | Jul 3, 2026 | Jul 6, 2026 |
| Okparaeke: financial policy | Ignatius Okparaeke | Standard financial policy | — | Sent | — | — |
| Pettibone: installment terms | Lazlo Pettibone | Installment terms | $150 | Sent | — | — |
| Strandberg-Osei: financial policy | Wilhelmina Strandberg-Osei | Standard financial policy | — | Signed | Jun 25, 2026 | Jun 28, 2026 |
Fee schedule
9 sample rows · 4 columnsWhat the clinic charges for each kind of visit, shot and test.
| Service | Code | Category | Fee |
|---|---|---|---|
| Established patient visit, brief | BC-101 | Office visit | $96 |
| Established patient visit, standard | BC-102 | Office visit | $148 |
| Established patient visit, extended | BC-103 | Office visit | $212 |
| New patient visit | BC-110 | Office visit | $235 |
| Annual physical | BC-120 | Preventive | $265 |
| School or sports physical | BC-121 | Preventive | $85 |
| Flu shot | BC-130 | Shots and tests | $42 |
| Strep test | BC-131 | Shots and tests | $38 |
| Blood draw | BC-132 | Shots and tests | $29 |
Forms and booking
New patient form
FormNew patient formThe page on the clinic website where a new patient registers before the first visit.
What is your full name? *
What is your date of birth?
Which number can we reach you on?
Where should we send your statements?
Who covers your visits?Superior Health AllianceLakehead MutualArrowhead Care PlanSelf-pay
Which member number is printed on your insurance card?
Register with Birchcombe CommonsEnter a visit bill
FormEnter a visit billWhat billing fills in after the provider closes a visit note.
What is the bill number? *It starts VB- and five digits.
Which patient was seen? *
Which service is being billed? *
Who saw the patient?
What day was the visit? *
What is the charge? *
How much will the insurer pay?
Save the billDashboards
Billing at a glance
Visit billsBills by status
- Paid18
- Sent7
- Overdue8
- Partly paid4
- Draft3
Collected by status
- Paid$593
- Sent$0
- Overdue$0
- Partly paid$95
- Draft$0
Charges by service$5,472
Also included
- Financial agreementDocumentWhat a patient signs to say how they will pay the part insurance does not cover.
- Billing boardStage rules
- Monday overdue listDigest
- Bill overdueNotificationTells billing the day a bill passes its due date unpaid.
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