| NAME AND ADDRESS DATA |
| Patient Name : | DOE, JOHN J |
| Address : | 123 MAIN STREET |
| City : | BUFFALO |
| State : | NY |
| Zip : | 14223 |
| Home Phone : | (716)555-1212 |
| HBOC Account Number : | 099999999-1094 |
| Medical Record Number : | 099999999 |
| Date of Birth : | 11/24/1922 |
| Gender : | M |
| Marital Status : | M |
| Race : | W |
| Religion : | CAT |
| | |
| VISIT DATA |
| Admission/Registration Date/Time : | 04/03/2001 08:44 |
| Discharge Date/Time : | 04/05/2001 14:02 |
|
| Chief Complaint : | HYPEROSMOLIC NON- KETONIC, C. DIFF |
| Patient Class : | I |
| Patient Type : | 17 |
| Facility : | MFHS |
| Location : | G8W |
| Room : | 0857 |
| Bed : | A |
| | |
| EMERGENCY CONTACT DATA |
| Relationship : | NONE |
| Home Phone : | |
| | |
| GUARANTOR DATA |
| Last Name : | DOE |
| First Name : | JOHN J |
| Relationship : | SELF |
| Address : | 123 MAIN STREET |
| City : | BUFFALO |
| State : | NY |
| Zip : | 14223 |
| Home Phone : | |
| | |
| INSURANCE DATA |
| Ins. Priority : | 3 |
| Ins. Plan Code : | B10 |
| Ins. Plan : | BC SUPPLEMENTAL |
| Ins. Policy : | YJB0999999999 |
| Ins. Fin. Class : | A |
| Ins. Group No. : | 999999 |
| Ins. Group Name : | B10 |
| Insured Last Name : | DOE |
| Insured First Name. : | JOHN J |
| Insured Relationship : | SELF |
| Insured SSN No. : | 123-12-1234 |
| | |
| Ins. Priority : | 1 |
| Ins. Plan Code : | M01 |
| Ins. Plan : | MEDICARE PART A ACUTE |
| Ins. Policy : | 123121234A |
| Ins. Fin. Class : | A |
| Insured Last Name : | DOE |
| Insured First Name. : | JOHN J |
| Insured Relationship : | NONE |
| Insured SSN No. : | 123-12-1234 |
| | |
| Ins. Priority : | 2 |
| Ins. Plan Code : | M02 |
| Ins. Plan : | MEDICARE B OUTPATIENT |
| Ins. Policy : | 123121234A |
| Ins. Fin. Class : | A |
| Insured Last Name : | DOE |
| Insured First Name. : | JOHN J |
| Insured Relationship : | NONE |
| Insured SSN No. : | 123-12-1234 |
| | |
| | |
| PHYSICIAN DATA |
| Primary Care Physician : | SMITH, JOHN | | 6/1/2013 2:28:44 PM to Current | | | ED visit Fax to current PCP was successfully sent on 6/1/2013 6:54:30 PM. |
|
| Admitting Physician : | WHITE, JOHN * | | Attending Physician : | WHITE, JOHN * | | Consulting Physician : | JONES, ROBERT |
|
| | |
| ALLERGY DATA |
| Substance | Category | Reactions | Severity | Type | Est. Onset | Reaction Sts. | Source | Reviewed | | NKA. | Drug | | | Allergy | | Active | | 6/1/2013 3:26:26 PM |
|