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