06/07/05

 

John Smith

DOB 06/07/05

SS# 100234567

123 Anystreet Rd

Yourtown NY 12345

Tel = 555 345 8799

Employ = Retired

Allergies:  Penicillin, Peanuts, Shellfish

1989 Surgery carpal tunnel = ICD-9 = 354.0

Dr.  Machom Better

100 Medical Lane

Yourtown NY 12345

Diag =  Rheum Arthrts = ICD-9 = 714.0

Comnts = Patient complains of thumb pain.

Ins = Ajax Mutual

111 50th St,  NYC  10001

Tel = 555 323 0001

Pol # 67854390

Request = Left Hand X-ray

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