data input module - repost

I need a module designed/written that has three data fields. I would like to be able to have the day's roster of patients populate forms that contain these input fields so that at the end of an encounter, the procedures and diagnoses that are relevant to each encounter can be recorded in a way that is at first editable and then insertable into my current billing program The first field "INSURANCE" allows for the input of several entities that control the output from the second field "PROCEDURE". I need to be able to add and delete entities in this field on an ongoing basis and to adjust the relationship that these entries have with the input data in PROCEDURE. If procedure ABC is entered into the "PROCEDURE" field, its output will vary based on the "INSURANCE" selected. The output from PROCEDURE will contain an alphanumeric code, a numeric code, a number of units, a description, and a charge per unit. Each of these data can be controlled by the choice of INSURANCE, The third field, DIAGNOSIS can similarly be updated and added/deleted on an ongoing basis. The data in DIAGNOSIS will be given an invisible category setting. The entries in DIAGNOSIS will require that an appropriate category DIAGNOSIS be paired with this entity. (the right to override this decision by applying a 'code' must be incorporated) The data in each of the three fields must be easily changed/updated/revised on an ongoing basis without code or computer knowledge. the output from the three fields will be printable on separate sheets and as a report in a WORD document that can be edited. reviewed and revised. A report must also be able to be generated that lists the same information in a date range that can be selected. After the written forms are reviewed, the data that is generated by the program must be inputtable into a program that currently carries my full data. Also, the forms in which these modules are embedded must be able to populate with the data from my program. I believe that this communication is achieved via HL7, but you will need to secure this connection. Note :payment will be done after completing project no milestone will be create.