1. The patient is seen by his family physician for follow-up treatment of recently diagnosed asthmatic bronchitis. The physician's fee is $75. The patient's copayment is $20. The patient's insurance plan covers 80% of the fee schedule amount of $60. No deductible is required.
2. Enter the amount the patient pays the provider: __________________
3. Enter the amount the payer reimburses the provider: ______________
4. Enter the amount the provider "writes off" the account: ____________