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:  
PAYMENT METHOD
# Status Type Preferred Card Holder Account Number Card Number Exp Date Last Date
1 Active CHG YES TEST, PATIENT 00100040     09/12/2008
2 Inactive VIS   TEST, PATIENT   XXXX-XXXX-XXXX-8298 12/10 08/08/2008
                 
A-Add Mode, C#-Change Mode, I#-Inactivate Mode, E-Exit, and press 'Enter'