Patient Information |
| Name: |
First nameJane |
LAST nameDoe |
MIQ |
| Address: |
123 Main Street, Apt 6
Anywhere, WI 53111 |
| Phone: |
Home414-123-4567 |
Cell414-567-8901 |
Work414-567-8901 |
| Patient DOB: |
04/04/1964 |
Gender: Female |
|
|
INSURANCE INFORMATION |
| Name: |
Access HealthNet |
| Address: |
161 W. Wisconsin Avenue
Box 53
Milwaukee, WI 53203 |
| Phone: |
(414) 249-5755 |
| Fax:
|
(414) 249-5759 |
| Email:
|
Kimber@accesshealthnet.com |
|
| Insured Name: |
First nameJohn |
LAST nameDoe |
| Insured Address: |
123 Main Street, Apt 6
Anywhere, WI 53111 |
| Insured Phone: |
414-123-4567 |
| Insured DOB: |
05/05/1964
|
| Relationship to Patient: |
Spouse
|
|
|
|
| Employer ID: |
ABC01 |
| Plan ID: |
123-55 |
|
| Group #: |
6789 |
| AHN Episode ID: |
080320161 |
|
|
REFERRING PHYSICIAN |
| Name: |
First nameJohn |
LAST nameSmith Md |
| Referring Location:
|
Smith Clinic |
| Office Phone: |
414-555-5555 |
| Office Fax:
|
414-555-5556 |
| Email:
|
info@joesmithclinic.com |
|
| Authorization obtrained: |
Yes |
| Authorization Number:
|
ABC01-9999999 |
| Exam or Service: |
MRI Knee without contrast
|
| Diagnosis: |
Pain following injury
|
|
|
|
| Patient Name: |
First nameJohn |
LAST nameSmith Md |
| Patient DOB:
|
04/04/1964 |
| Date: |
08/08/2016 |
| Exam(s)/Service(s) Diagnosis:
|
MRI Knee without contrast |
| Diagnosis:
|
Pain following injury
|
|
| Ordering Provider: |
First nameJohn |
LAST nameSmith Md |
| Signature: |
 |
| Order Entered By: |
First nameThomas |
LAST nameJohnson |
|
|
|
|
© Copyright 2016. All Rights Reserved.
|
Powered by Access HealthNet LLC. 
|
|
