1234 Main Street (999) 999-9999 Hospital City, ST 999999999 Patient Information Patient Name: Smith, Joe Sex: Male Preferred Name: DOB: 99/99/9999 Home Address: 64 Some ST Age: 89 Years City, State 999999999 SSN: XXX-XX-XXXX Home Phone: (999) 999-9999 Interpretation Required: Employer Name: retired CellPhone : Employer Phone: Guarantor Information Guarantor Name: Smith, Joe Patient's Reltn: SELF Mailing Address: 64 Some ST Sex: Male City, State 999999999 DOB: 99/99/9999 Phone: (999) 999-9999 SSN: XXX-XX-XXXX Employer Name: retired ALT Phone # : Employer Phone: Contact Information Emergency Contact Next of Kin Contact Name: Smith, SUE Contact Name: Smith, BILL Patient's Reltn: Mother Patient's Reltn: Mother Sex: Sex: Home Phone: (999) 999-9999 Home Phone: (999) 999-9999 ALT Phone # : (999) 999-9999 ALT Phone # : Primary Insurance Subscriber Name: Smith, Joe Insurance Name: Medicare A and B Patient's Reltn: SELF Claim Address: 1234 Main St Sex: Male City, State 999999999 DOB: 99/99/9999 Insurance Phone: (999) 999-9999 Age: 89 Years Policy Number: 9999999999 Employer Name: retired Group Number: Employer Phone: Secondary Insurance Subscriber Name: Smith, Joe Insurance Name: Care Patient's Reltn: SELF Claim Address: 1234 Main St Sex: Male City, State 99999 DOB: 99/99/9999 Insurance Phone: (999) 999-9999 Age: 89 Years Policy Number: 999999A Employer Name: retired Group Number: Employer Phone: Tertiary Insurance Subscriber Name: Insurance Name: Patient's Reltn: Claim Address: Sex: DOB: Insurance Phone: Age: Policy Number: Employer Name: Employer Phone: Group Number: Encounter Information Reg Dt/Tm: 99/99/9999 02:53 Patient Type: Inpatient Visit Type: Emergency Est Dt of Arrival: 99/99/9999 09:00 Medical Service: General Medicine Referral Source: Self Referral Observation Dt/Tm: Location: CM M4 Reg Clerk: LastName, FirstName Inpt Adm Dt/Tm: 99/99/9999 08:35 Room/Bed: 492 / 1 Admit Physician: Jones MD, Joe Disch Dt/Tm: How Arrived: Ambulance Attend Physician: Jones MD, Joe Visit Reason: Gastrointestional bleed PCP: Jones MD, Joe Smith, Joe Male / 89 Years MRN: CM00000000 FIN: 9999-9999 A00A00A00A00A00A00A00A00A00A00A00A00A00 Printed By: Jones MD, Joe on 99/99/9999 04:10 Registration last updated by: LastName RN, FirstName on 99/99/9999 16:54 Page 1 of 5 = Page 1 = Hospital 1234 Main Street Copies to: Jones MD,Joe City, State 99999 CM Adult Hospitalists Phone: (999) 999-9999 Fax: (999) 999-9999 1234 Main Street City, State Patient: Smith, Joe MRN: CM000909 Account: 9999-99999 DOB/Sex: 99/99/9999 Male Pt Type: Inpatient Attending: Jones MD, Joe Perioperative Document Print Date/Time: 99/99/9999 04:10 EDT Page 2 of 5 Report Request ID: 123456 = Page 2 = * Auth (Verified) * Page 3 of 5 $image-no-number$ = Page 3 = * Auth (Verified) * Page 4 of 5 $image-no-number$ = Page 4 = * Auth (Verified) * Page 5 of 5 $image-no-number$ = Page 5 = 1234 Main Street (999) 999-9999 Hospital City, ST 999999999 Patient Information Patient Name: Smith, Joe Sex: Male Preferred Name: DOB: 99/99/9999 Home Address: 64 Some ST Age: 89 Years City, State 999999999 SSN: XXX-XX-XXXX Home Phone: (999) 999-9999 Interpretation Required: Employer Name: retired CellPhone : Employer Phone: Guarantor Information Guarantor Name: Smith, Joe Patient's Reltn: SELF Mailing Address: 64 Some ST Sex: Male City, State 999999999 DOB: 99/99/9999 Phone: (999) 999-9999 SSN: XXX-XX-XXXX Employer Name: retired ALT Phone # : Employer Phone: Contact Information Emergency Contact Next of Kin Contact Name: Smith, SUE Contact Name: Smith, BILL Patient's Reltn: Mother Patient's Reltn: Mother Sex: Sex: Home Phone: (999) 999-9999 Home Phone: (999) 999-9999 ALT Phone # : (999) 999-9999 ALT Phone # : Primary Insurance Subscriber Name: Smith, Joe Insurance Name: Medicare A and B Patient's Reltn: SELF Claim Address: 1234 Main St Sex: Male City, State 999999999 DOB: 99/99/9999 Insurance Phone: (999) 999-9999 Age: 89 Years Policy Number: 9999999999 Employer Name: retired Group Number: Employer Phone: Secondary Insurance Subscriber Name: Smith, Joe Insurance Name: Care Patient's Reltn: SELF Claim Address: 1234 Main St Sex: Male City, State 99999 DOB: 99/99/9999 Insurance Phone: (999) 999-9999 Age: 89 Years Policy Number: 999999A Employer Name: retired Group Number: Employer Phone: Tertiary Insurance Subscriber Name: Insurance Name: Patient's Reltn: Claim Address: Sex: DOB: Insurance Phone: Age: Policy Number: Employer Name: Employer Phone: Group Number: Encounter Information Reg Dt/Tm: 99/99/9999 02:53 Patient Type: Inpatient Visit Type: Emergency Est Dt of Arrival: 99/99/9999 09:00 Medical Service: General Medicine Referral Source: Self Referral Observation Dt/Tm: Location: CM M4 Reg Clerk: LastName, FirstName Inpt Adm Dt/Tm: 99/99/9999 08:35 Room/Bed: 492 / 1 Admit Physician: Jones MD, Joe Disch Dt/Tm: How Arrived: Ambulance Attend Physician: Jones MD, Joe Visit Reason: Gastrointestional bleed PCP: Jones MD, Joe Smith, Joe Male / 89 Years MRN: CM00000000 FIN: 9999-9999 A00A00A00A00A00A00A00A00A00A00A00A00A00 Printed By: Jones MD, Joe on 99/99/9999 04:10 Registration last updated by: LastName RN, FirstName on 99/99/9999 16:54 Page 1 of 5 = Page 1 = Hospital 1234 Main Street Copies to: Jones MD,Joe City, State 99999 CM Adult Hospitalists Phone: (999) 999-9999 Fax: (999) 999-9999 1234 Main Street City, State Patient: Smith, Joe MRN: CM000909 Account: 9999-99999 DOB/Sex: 99/99/9999 Male Pt Type: Inpatient Attending: Jones MD, Joe Perioperative Document Print Date/Time: 99/99/9999 04:10 EDT Page 2 of 5 Report Request ID: 123456 = Page 2 = * Auth (Verified) * Page 3 of 5 $image-no-number$ = Page 3 = * Auth (Verified) * Page 4 of 5 $image-no-number$ = Page 4 = * Auth (Verified) * Page 5 of 5 $image-no-number$ = Page 5 = 1234 Main Street (999) 999-9999 Hospital City, ST 999999999 Patient Information Patient Name: Smith, Joe Sex: Male Preferred Name: DOB: 99/99/9999 Home Address: 64 Some ST Age: 89 Years City, State 999999999 SSN: XXX-XX-XXXX Home Phone: (999) 999-9999 Interpretation Required: Employer Name: retired CellPhone : Employer Phone: Guarantor Information Guarantor Name: Smith, Joe Patient's Reltn: SELF Mailing Address: 64 Some ST Sex: Male City, State 999999999 DOB: 99/99/9999 Phone: (999) 999-9999 SSN: XXX-XX-XXXX Employer Name: retired ALT Phone # : Employer Phone: Contact Information Emergency Contact Next of Kin Contact Name: Smith, SUE Contact Name: Smith, BILL Patient's Reltn: Mother Patient's Reltn: Mother Sex: Sex: Home Phone: (999) 999-9999 Home Phone: (999) 999-9999 ALT Phone # : (999) 999-9999 ALT Phone # : Primary Insurance Subscriber Name: Smith, Joe Insurance Name: Medicare A and B Patient's Reltn: SELF Claim Address: 1234 Main St Sex: Male City, State 999999999 DOB: 99/99/9999 Insurance Phone: (999) 999-9999 Age: 89 Years Policy Number: 9999999999 Employer Name: retired Group Number: Employer Phone: Secondary Insurance Subscriber Name: Smith, Joe Insurance Name: Care Patient's Reltn: SELF Claim Address: 1234 Main St Sex: Male City, State 99999 DOB: 99/99/9999 Insurance Phone: (999) 999-9999 Age: 89 Years Policy Number: 999999A Employer Name: retired Group Number: Employer Phone: Tertiary Insurance Subscriber Name: Insurance Name: Patient's Reltn: Claim Address: Sex: DOB: Insurance Phone: Age: Policy Number: Employer Name: Employer Phone: Group Number: Encounter Information Reg Dt/Tm: 99/99/9999 02:53 Patient Type: Inpatient Visit Type: Emergency Est Dt of Arrival: 99/99/9999 09:00 Medical Service: General Medicine Referral Source: Self Referral Observation Dt/Tm: Location: CM M4 Reg Clerk: LastName, FirstName Inpt Adm Dt/Tm: 99/99/9999 08:35 Room/Bed: 492 / 1 Admit Physician: Jones MD, Joe Disch Dt/Tm: How Arrived: Ambulance Attend Physician: Jones MD, Joe Visit Reason: Gastrointestional bleed PCP: Jones MD, Joe Smith, Joe Male / 89 Years MRN: CM00000000 FIN: 9999-9999 A00A00A00A00A00A00A00A00A00A00A00A00A00 Printed By: Jones MD, Joe on 99/99/9999 04:10 Registration last updated by: LastName RN, FirstName on 99/99/9999 16:54 Page 1 of 5 = Page 1 = Hospital 1234 Main Street Copies to: Jones MD,Joe City, State 99999 CM Adult Hospitalists Phone: (999) 999-9999 Fax: (999) 999-9999 1234 Main Street City, State Patient: Smith, Joe MRN: CM000909 Account: 9999-99999 DOB/Sex: 99/99/9999 Male Pt Type: Inpatient Attending: Jones MD, Joe Perioperative Document Print Date/Time: 99/99/9999 04:10 EDT Page 2 of 5 Report Request ID: 123456 = Page 2 = * Auth (Verified) * Page 3 of 5 $image-no-number$ = Page 3 = * Auth (Verified) * Page 4 of 5 $image-no-number$ = Page 4 = * Auth (Verified) * Page 5 of 5 $image-no-number$ = Page 5 = 1234 Main Street (999) 999-9999 Hospital City, ST 999999999 Patient Information Patient Name: Smith, Joe Sex: Male Preferred Name: DOB: 99/99/9999 Home Address: 64 Some ST Age: 89 Years City, State 999999999 SSN: XXX-XX-XXXX Home Phone: (999) 999-9999 Interpretation Required: Employer Name: retired CellPhone : Employer Phone: Guarantor Information Guarantor Name: Smith, Joe Patient's Reltn: SELF Mailing Address: 64 Some ST Sex: Male City, State 999999999 DOB: 99/99/9999 Phone: (999) 999-9999 SSN: XXX-XX-XXXX Employer Name: retired ALT Phone # : Employer Phone: Contact Information Emergency Contact Next of Kin Contact Name: Smith, SUE Contact Name: Smith, BILL Patient's Reltn: Mother Patient's Reltn: Mother Sex: Sex: Home Phone: (999) 999-9999 Home Phone: (999) 999-9999 ALT Phone # : (999) 999-9999 ALT Phone # : Primary Insurance Subscriber Name: Smith, Joe Insurance Name: Medicare A and B Patient's Reltn: SELF Claim Address: 1234 Main St Sex: Male City, State 999999999 DOB: 99/99/9999 Insurance Phone: (999) 999-9999 Age: 89 Years Policy Number: 9999999999 Employer Name: retired Group Number: Employer Phone: Secondary Insurance Subscriber Name: Smith, Joe Insurance Name: Care Patient's Reltn: SELF Claim Address: 1234 Main St Sex: Male City, State 99999 DOB: 99/99/9999 Insurance Phone: (999) 999-9999 Age: 89 Years Policy Number: 999999A Employer Name: retired Group Number: Employer Phone: Tertiary Insurance Subscriber Name: Insurance Name: Patient's Reltn: Claim Address: Sex: DOB: Insurance Phone: Age: Policy Number: Employer Name: Employer Phone: Group Number: Encounter Information Reg Dt/Tm: 99/99/9999 02:53 Patient Type: Inpatient Visit Type: Emergency Est Dt of Arrival: 99/99/9999 09:00 Medical Service: General Medicine Referral Source: Self Referral Observation Dt/Tm: Location: CM M4 Reg Clerk: LastName, FirstName Inpt Adm Dt/Tm: 99/99/9999 08:35 Room/Bed: 492 / 1 Admit Physician: Jones MD, Joe Disch Dt/Tm: How Arrived: Ambulance Attend Physician: Jones MD, Joe Visit Reason: Gastrointestional bleed PCP: Jones MD, Joe Smith, Joe Male / 89 Years MRN: CM00000000 FIN: 9999-9999 A00A00A00A00A00A00A00A00A00A00A00A00A00 Printed By: Jones MD, Joe on 99/99/9999 04:10 Registration last updated by: LastName RN, FirstName on 99/99/9999 16:54 Page 1 of 5 = Page 1 = Hospital 1234 Main Street Copies to: Jones MD,Joe City, State 99999 CM Adult Hospitalists Phone: (999) 999-9999 Fax: (999) 999-9999 1234 Main Street City, State Patient: Smith, Joe MRN: CM000909 Account: 9999-99999 DOB/Sex: 99/99/9999 Male Pt Type: Inpatient Attending: Jones MD, Joe Perioperative Document Print Date/Time: 99/99/9999 04:10 EDT Page 2 of 5 Report Request ID: 123456 = Page 2 = * Auth (Verified) * Page 3 of 5 $image-no-number$ = Page 3 = * Auth (Verified) * Page 4 of 5 $image-no-number$ = Page 4 = * Auth (Verified) * Page 5 of 5 $image-no-number$ = Page 5 = 1234 Main Street (999) 999-9999 Hospital City, ST 999999999 Patient Information Patient Name: Smith, Joe Sex: Male Preferred Name: DOB: 99/99/9999 Home Address: 64 Some ST Age: 89 Years City, State 999999999 SSN: XXX-XX-XXXX Home Phone: (999) 999-9999 Interpretation Required: Employer Name: retired CellPhone : Employer Phone: Guarantor Information Guarantor Name: Smith, Joe Patient's Reltn: SELF Mailing Address: 64 Some ST Sex: Male City, State 999999999 DOB: 99/99/9999 Phone: (999) 999-9999 SSN: XXX-XX-XXXX Employer Name: retired ALT Phone # : Employer Phone: Contact Information Emergency Contact Next of Kin Contact Name: Smith, SUE Contact Name: Smith, BILL Patient's Reltn: Mother Patient's Reltn: Mother Sex: Sex: Home Phone: (999) 999-9999 Home Phone: (999) 999-9999 ALT Phone # : (999) 999-9999 ALT Phone # : Primary Insurance Subscriber Name: Smith, Joe Insurance Name: Medicare A and B Patient's Reltn: SELF Claim Address: 1234 Main St Sex: Male City, State 999999999 DOB: 99/99/9999 Insurance Phone: (999) 999-9999 Age: 89 Years Policy Number: 9999999999 Employer Name: retired Group Number: Employer Phone: Secondary Insurance Subscriber Name: Smith, Joe Insurance Name: Care Patient's Reltn: SELF Claim Address: 1234 Main St Sex: Male City, State 99999 DOB: 99/99/9999 Insurance Phone: (999) 999-9999 Age: 89 Years Policy Number: 999999A Employer Name: retired Group Number: Employer Phone: Tertiary Insurance Subscriber Name: Insurance Name: Patient's Reltn: Claim Address: Sex: DOB: Insurance Phone: Age: Policy Number: Employer Name: Employer Phone: Group Number: Encounter Information Reg Dt/Tm: 99/99/9999 02:53 Patient Type: Inpatient Visit Type: Emergency Est Dt of Arrival: 99/99/9999 09:00 Medical Service: General Medicine Referral Source: Self Referral Observation Dt/Tm: Location: CM M4 Reg Clerk: LastName, FirstName Inpt Adm Dt/Tm: 99/99/9999 08:35 Room/Bed: 492 / 1 Admit Physician: Jones MD, Joe Disch Dt/Tm: How Arrived: Ambulance Attend Physician: Jones MD, Joe Visit Reason: Gastrointestional bleed PCP: Jones MD, Joe Smith, Joe Male / 89 Years MRN: CM00000000 FIN: 9999-9999 A00A00A00A00A00A00A00A00A00A00A00A00A00 Printed By: Jones MD, Joe on 99/99/9999 04:10 Registration last updated by: LastName RN, FirstName on 99/99/9999 16:54 Page 1 of 5 = Page 1 = Hospital 1234 Main Street Copies to: Jones MD,Joe City, State 99999 CM Adult Hospitalists Phone: (999) 999-9999 Fax: (999) 999-9999 1234 Main Street City, State Patient: Smith, Joe MRN: CM000909 Account: 9999-99999 DOB/Sex: 99/99/9999 Male Pt Type: Inpatient Attending: Jones MD, Joe Perioperative Document Print Date/Time: 99/99/9999 04:10 EDT Page 2 of 5 Report Request ID: 123456 = Page 2 = * Auth (Verified) * Page 3 of 5 $image-no-number$ = Page 3 = * Auth (Verified) * Page 4 of 5 $image-no-number$ = Page 4 = * Auth (Verified) * Page 5 of 5 $image-no-number$ = Page 5 = 1234 Main Street (999) 999-9999 Hospital City, ST 999999999 Patient Information Patient Name: Smith, Joe Sex: Male Preferred Name: DOB: 99/99/9999 Home Address: 64 Some ST Age: 89 Years City, State 999999999 SSN: XXX-XX-XXXX Home Phone: (999) 999-9999 Interpretation Required: Employer Name: retired CellPhone : Employer Phone: Guarantor Information Guarantor Name: Smith, Joe Patient's Reltn: SELF Mailing Address: 64 Some ST Sex: Male City, State 999999999 DOB: 99/99/9999 Phone: (999) 999-9999 SSN: XXX-XX-XXXX Employer Name: retired ALT Phone # : Employer Phone: Contact Information Emergency Contact Next of Kin Contact Name: Smith, SUE Contact Name: Smith, BILL Patient's Reltn: Mother Patient's Reltn: Mother Sex: Sex: Home Phone: (999) 999-9999 Home Phone: (999) 999-9999 ALT Phone # : (999) 999-9999 ALT Phone # : Primary Insurance Subscriber Name: Smith, Joe Insurance Name: Medicare A and B Patient's Reltn: SELF Claim Address: 1234 Main St Sex: Male City, State 999999999 DOB: 99/99/9999 Insurance Phone: (999) 999-9999 Age: 89 Years Policy Number: 9999999999 Employer Name: retired Group Number: Employer Phone: Secondary Insurance Subscriber Name: Smith, Joe Insurance Name: Care Patient's Reltn: SELF Claim Address: 1234 Main St Sex: Male City, State 99999 DOB: 99/99/9999 Insurance Phone: (999) 999-9999 Age: 89 Years Policy Number: 999999A Employer Name: retired Group Number: Employer Phone: Tertiary Insurance Subscriber Name: Insurance Name: Patient's Reltn: Claim Address: Sex: DOB: Insurance Phone: Age: Policy Number: Employer Name: Employer Phone: Group Number: Encounter Information Reg Dt/Tm: 99/99/9999 02:53 Patient Type: Inpatient Visit Type: Emergency Est Dt of Arrival: 99/99/9999 09:00 Medical Service: General Medicine Referral Source: Self Referral Observation Dt/Tm: Location: CM M4 Reg Clerk: LastName, FirstName Inpt Adm Dt/Tm: 99/99/9999 08:35 Room/Bed: 492 / 1 Admit Physician: Jones MD, Joe Disch Dt/Tm: How Arrived: Ambulance Attend Physician: Jones MD, Joe Visit Reason: Gastrointestional bleed PCP: Jones MD, Joe Smith, Joe Male / 89 Years MRN: CM00000000 FIN: 9999-9999 A00A00A00A00A00A00A00A00A00A00A00A00A00 Printed By: Jones MD, Joe on 99/99/9999 04:10 Registration last updated by: LastName RN, FirstName on 99/99/9999 16:54 Page 1 of 5 = Page 1 = Hospital 1234 Main Street Copies to: Jones MD,Joe City, State 99999 CM Adult Hospitalists Phone: (999) 999-9999 Fax: (999) 999-9999 1234 Main Street City, State Patient: Smith, Joe MRN: CM000909 Account: 9999-99999 DOB/Sex: 99/99/9999 Male Pt Type: Inpatient Attending: Jones MD, Joe Perioperative Document Print Date/Time: 99/99/9999 04:10 EDT Page 2 of 5 Report Request ID: 123456 = Page 2 = * Auth (Verified) * Page 3 of 5 $image-no-number$ = Page 3 = * Auth (Verified) * Page 4 of 5 $image-no-number$ = Page 4 = * Auth (Verified) * Page 5 of 5 $image-no-number$ = Page 5 =