PATIENT INFORMATION
COVERAGES
MODE OF PAYMENT
PT# :
00100050
PATIENT INFORMATION
Name:
TEST, PATIENT
Address1:
2505 S. FINLEY RD.
City/State/ZIP:
LOMBARD, IL 60148
Comment:
DOB:
02/01/1970
Primary Phone:
985-647-1235
Secondary Phone:
Gender:
Female
Language:
English
Member No:
CC000000000
COVERAGE SELECTION
#
Status
Type
Coverage
BIN
PCN
Group
ID Number
PC
Cardholder
Med D
Term Date
1
Active
P
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'