PATIENT INFORMATION PT#: 00100050
Name:
TEST, PATIENT
DOB:
02/01/1970
Gender:
Female
Address 1:
2505 S. FINLEY RD.
Primary Phone:
985-647-1235
Language:
English
City/State/ZIP:
LOMBARD, IL 60148
Secondary Phone:
Member No:
CC000000000
Comment:
ADD COVERAGE
Coverage:
ADJ
ACS
TST
Person Code:
Benefit:
Plan:
Plan 1
Plan 2
None
*
Cardholder:
PTD Remain:
0.00
Group:
Group 1
Group 2
None
*
Relationship:
Cardholder
Husband
Wife
Son
Daughter
PTD Date:
00/00/0000
*
ID Number:
Effective:
PTD Count:
0
Sequence Ind:
1
2
3
4
5
Expiration:
PTD Count Limit:
0
Status:
Active
Inactive
Brand Copay:
PTD Total:
0.00
Created:
Generic Copay:
PTD Total Limit:
0
Modified:
S No
Document
1
Add Coverage
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