**Document Status Report**

Identifies the status of a document for a requested period of time. The
report shows whether documents are paid, open, or cancelled. CHS offers
the option to report on all documents that are open, all documents that
are closed, or a combination of the two. The following sample is a
report showing all documents that are open and closed.

WHITE,DAVID Page 1

\*\*\* CONTRACT HEALTH MANAGEMENT SYSTEM \*\*\*

TRAINING DATABASE

DOCUMENT STATUS REPORT

Jun 10, 2003@14:54:19

OPEN AND CLOSED DOCUMENTS

For the period Jan 01, 2003 through Jun 10, 2003

Patient Name Provider of Service Issue /DOS

Document number EIN Number Type Status Amount

===============================================================================

UTULA,FAWN LYNNSTARR DUNHAM CLINIC 051903 PAID 899.00

3-Q25-00001 1850105601 B4 HOSPITAL

UTULA,FAWN LYNNSTARR DUNHAM CLINIC 051903 150.00

3-Q25-00002 1850105601 B4 OUTPATIENT

UTULA,FAWN LYNNSTARR SUNRISE DENTAL 051903 600.00

3-Q25-00003 1841076784 A1 DENTAL

SENDUVEL,JEFFREY JEROME DUNHAM CLINIC 052003 100.00

3-Q25-00036 1850105601 B4 OUTPATIENT

BELTEZER,TOM GERALD CHAMPION 052003 3,000.00

3-Q25-00005 1850138775 A1 HOSPITAL

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

TOTAL PAID DOCUMENTS: 01 TOTAL DOLLARS PAID: \$9,499.00

TOTAL OPEN DOCUMENTS: 04 TOTAL DOLLARS OPEN: \$19,525.00

TOTAL CANCELLED DOCUMENTS: 0 TOTAL DOLLARS CANCELLED: \$0

# 

# Expenditure Report

The financial reports on pages 5-A-3 and 5-A-4 show expenditures for the
following options over a designated period of time:

### Patient

### Community of residence

### Age group

### Totals only

### By tribe

Once the above selection is made expenditures can then be shown by

### Inpatient Services

### Outpatient Services

### Dental Services

### Combination of all services.

The following is a sample patient expenditure report showing
expenditures for all services.

\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*

TRAINING DATABASE

Jun 10, <2003@15:57:09> CHS EXPENDITURE REPORT BY PATIENT Page: 1

Jan 01, 2003 Thru Jun 10, 2003

\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*

All Expenditures for TRAINING DATABASE for Paid Authorizations issued
Between Jan 01, 2003 Thru Jun 10, 2003

Patient \# #43 Total \# #64 Total \# Total Wkl 3^rd^ Party

43s Days Dol 64s Days Dol 57s Dol Dol

DOB Community

==============================================================================================

BELTEZER,TOM 1 3 3,000.00 0 0 0.00 0 0.00 0.00 3,000.00

05-18-1963 DULCE

CAVAZONE,BLAIR REED 0 0 0.00 0 0 0.00 1 350.00 0.00 350.00

05-04-2001 CANONCITO

LERGU,DANNY ALEXIS 1 5 1,000.00 1 0 100.00 0 0.00 800.00 1,900.00

05-03-1940 DULCE

MERTYNAZ,CHERYL LYNN 1 5 1,000.00 1 0 600.00 0 0.00 0.00 1,600.00

03-21-1952 DULCE

MUNERCU,SANDY K 1 5 1,000.00 1 0 600.00 0 0.00 800.00 2,400.00

02-28-1943 DULCE

MUNTUIE,FAWN LYNNSTARR 1 5 5,000.00 1 0 100.00 0 0.00 0.00 5,100.00

05-14-1957 DULCE

REMUN,JOSEPH A 1 5 1,000.00 2 0 700.00 1 500.00 800.00 3,000.00

07-11-1940 DULCE

SENDUVEL,JEFFREY JEROME 1 5 1,000.00 3 0 1,200.00 1 500.00 0.00 2,700.00

07-18-1943 DULCE

UTULA,FAWN LYNNSTARR 2 8 1,899.00 4 0 1,350.00 2 1,100.00 500.00
4,849.00

10-15-1962 DULCE

VALERDA,ALBERT J 1 3 1,000.00 0 0 0.00 0 0.00 0.00 1,000.00

01-08-1993 DULCE

VELDAZ,DAPHNE LELAINE 1 5 1,000.00 0 0 0.00 0 0.00 0.00 1,000.00

04-06-1954 MESCALERO OS

VYCANTY,JODON NICHOLA 1 5 1,200.00 4 0 1,375.00 1 250.00 1,050.00
3,875.00

03-13-1964 DULCE

WENUSKYE,NORALEEN 1 5 2,000.00 1 0 1,000.00 0 0.00 500.00 3,500.00

06-29-1964 DULCE

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--

Total 13 59 20,099.00 18 0 7,025.00 6 2,700.00 4,450.00 34,274.00

\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*

TRAINING DATABASE

Jun 10, <2003@15:57:09> CHS EXPENDITURE REPORT BY PATIENT Page: 2

Jan 01, 2003 Thru Jun 10, 200

\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*\*

All Expenditures for TRAINING DATABASE for Paid Authorizations issued
Between Jan 01, 2003 Thru Jun 10, 2003

Total Patients for Period\...\...\...\...\...\...\...\...\...\...\....13

Total 43 Documents for period\...\...\...\...\...\...\...\...13

Total 43 Estimated Days of care\...\...\...\...\...\...\....59

Total 43 Dollars\...\...\...\...\...\...\...\...\...\...\...\$20,099.00

Total 64 Documents for period\...\...\...\...\...\...\...\...18

Total 64 Estimated Days of Care\...\...\...\...\...\...\.....0

Total 64 Dollars\...\...\...\...\...\...\...\...\...\...\.....\$7,025.00

Total 57 Documents for period\...\...\...\...\...\...\...\.....6

Total 57 Dollars\...\...\...\...\...\...\...\...\...\...\.....\$2,700.00

Total Third Party Payments\...\...\...\...\.....\$4,450.00

Total Dollars for Period\...\...\...\...\...\...\...\$34,274.00

## 

## Document Summary Report

The document summary report shows financial activity on purchase orders
over a designated period of time.

TRAINING DATABASE

CHS DOCUMENT SUMMARY REPORT Page 1

Jun 11, 2003@09:27:52

May 01, 2003 Thru May 31, 2003

Patient Provider of Service Issue /DOS Type

Document Ein \# Serv Dest Amount

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--
\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-- \-\-\-\-\-\-\-\-\-\--
\-\-\-\-\-\-- \-\-\-\-\-\-\--

UTULA,FAWN LYNNSTARR DUNHAM CLINIC 051903 INIT 800.00

3-Q25-00001 1850105601 HOSPITAL FI

UTULA,FAWN LYNNSTARR DUNHAM CLINIC 052003/0519 P \> Obl 99.00

3-Q25-00001 1850105601 HOSPITAL FI

UTULA,FAWN LYNNSTARR DUNHAM CLINIC 051903 INIT 150.00

3-Q25-00002 1850105601 OUTPAT FI

UTULA,FAWN LYNNSTARR SUNRISE DENTAL CARE 051903 INIT 600.00

3-Q25-00003 1841076784 DENTAL FI

UTULA,FAWN LYNNSTARR SUNRISE DENTAL CARE 052003/0420 INT-PMT 600.00

3-Q25-00003 1841076784 DENTAL FI NOT IN TOTALS

MUNTUIE,FAWN LYNNSTA UNM HOSPITAL/BCMC 052003 INIT 5000.00

3-Q25-00004 2999999999 HOSPITAL FI

TRAINING DATABASE

CHS DOCUMENT SUMMARY REPORT Page 2

Jun 11, 2003@09:31:56

May 01, 2003 Thru May 31, 2003

Type Document No. Documents Obligations

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-- \-\-\-\-\-\-\-\-\-\-\-\-\--
\-\-\-\-\-\-\-\-\-\-\-\-\--

INITIAL DOCUMENTS 37 \$30,125.00

SUPPLEMENTAL DOCUMENTS

CANCEL DOCUMENTS 1 (\$800.00)

PAYMENT DOCUMENTS 3 (\$301.00)

INTERIM PAYMENT DOCUMENTS 1 \$600.00

\_\_\_\_\_\_\_\_ \_\_\_\_\_\_\_\_\_\_\_\_\_

TOTALS 42 \$29,624.00

FISCAL AGENT DOCUMENTS: 49

IHS DOCUMENTS: 1

Press RETURN To Continue or Escape to Cancel\...:

TRAINING DATABASE

CHS DOCUMENT SUMMARY REPORT Page 3

Jun 11, 2003@09:31:56

May 01, 2003 Thru May 31, 2003

Register Beginning Increased Decreased Net Ending

Balance Amount Amount Change Balance

\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-- \-\-\-\-\-\-\-\-\-\-\--
\-\-\-\-\-\-\-\-\-- \-\-\-\-\-\-\-\-\-- \-\-\-\-\-\-\-\-\--
\-\-\-\-\-\-\-\-\-\--

HOSP INPT 20,099.00 800.00 19,299.00 19,299.00

HOSPITAL OP 0.00 0.00 0.00 0.00

PHYSICIAN IP 1,700.00 0.00 1,700.00 1,700.00

PHYSICIAN OP 1,825.00 0.00 1,825.00 1,825.00

DENTAL CARE 3,100.00 400.00 2,700.00 2,700.00

P & E TRAVEL 3,500.00 0.00 3,500.00 3,500.00

ALL OTHER CHS 0.00 0.00 0.00 0.00

\-\-\-\-\-\-\-\-\-\-\-- \-\-\-\-\-\-\-\-\-- \-\-\-\-\-\-\-\-\--
\-\-\-\-\-\-\-\-\-- \-\-\-\-\-\-\-\-\-\--

TOTAL 30,224.00 1,200.00 29,024.00 29,024.00

Obligated Balance For Period: \$29,024.00