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:  
COVERAGE SELECTION
# Status Coverage BIN PCN Group ID Number PC Cardholder Med D Term Date
1 Active ADJ   1234567890 Group 1 494943939   Test, Patient   09/12/2008
2 Inactive QAT 001553 NHINY2K 1234566322 98992888200235 001 Test, Mary Y 08/08/2007
A-Add Coverage, C#-Change Coverage, I#-Inactivate Coverage, E-Exit, and press 'Enter'