{% extends 'base.html' %} {% load static %} {% block title %}Submit Bill{% endblock %} {% block content %}

Submit Bill for Processing

Bill Summary

Bill Number:
{{ bill.bill_number }}
Patient:
{{ bill.patient.first_name }} {{ bill.patient.last_name }}
Patient ID:
{{ bill.patient.patient_id }}
Service Date:
{{ bill.service_date|date:"M d, Y" }}
Total Amount:
${{ bill.total_amount|floatformat:2 }}
Insurance:
{{ bill.insurance_plan.name|default:"Self-Pay" }}
Current Status:
{% if bill.status == 'draft' %} Draft {% elif bill.status == 'pending' %} Pending {% elif bill.status == 'submitted' %} Submitted {% elif bill.status == 'paid' %} Paid {% endif %}
Created:
{{ bill.created_at|date:"M d, Y g:i A" }}

Pre-submission Validation

Running validation checks...
{% if submission_history %}

Previous Submission Attempts

{% for history in submission_history %} {% endfor %}
Date Method Status Notes Submitted By
{{ history.submitted_at|date:"M d, Y g:i A" }} {{ history.method|title }} {% if history.status == 'success' %} Success {% elif history.status == 'failed' %} Failed {% elif history.status == 'pending' %} Pending {% endif %} {{ history.notes|default:"—" }} {{ history.submitted_by }}
{% endif %}
{% endblock %} {% block js %} {% endblock %}