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
OTHER MEDICATIONS
#
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
Inactivate this mode?
Y
-Yes,
N
-No, and press 'Enter'
A
-Add Mode,
C#
-Change Mode,
I#
-Inactivate Mode,
E
-Exit, and press 'Enter'