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--------------------------------
MYMEDICARE.GOV PERSONAL HEALTH INFORMATION
--------------------------------
**********CONFIDENTIAL***********
Produced by the Blue Button (v2.0)
03/16/2013 5:10 AM
--------------------------------
Demographic
--------------------------------
Source: MyMedicare.gov
Name: Isabella Isa Jones
Date of Birth: 05/01/1975
Address Line 1: 1357 Amber Drive
Address Line 2:
City: Beaverton
State: OR
Zip: 97867
Phone Number: (816)276-6909
Email: [email protected]
Part A Effective Date: 01/01/2012
Part B Effective Date: 01/01/2012
--------------------------------
Emergency Contact
--------------------------------
Source: Self-Entered
Contact Name: JANE DOE
Address Type:Home
Address Line 1: 123 AnyWhere St
Address Line 2:
City: AnyWhere
State: DC
Zip: 00002-1111
Relationship: Other
Home Phone: 123-456-7890
Work Phone: 000-001-0001
Mobile Phone: 000-001-0002
Email Address: [email protected]
Contact Name: STEVE DOE
Address Type:
Address Line 1: 123 AnyWhere Rd
Address Line 2:
City: AnyWhere
State: VA
Zip: 00001
Relationship: Other
Home Phone: 123-456-7890
Work Phone: 000-001-0001
Mobile Phone: 000-001-0002
Email Address: [email protected]
--------------------------------
Self Reported Medical Conditions
--------------------------------
Source: Self-Entered
Condition Name: Pneumonia
Medical Condition Start Date: 01/03/2008
Medical Condition End Date: 01/03/2008
Condition Name: Asthma
Medical Condition Start Date: 01/03/2007
Medical Condition End Date: 01/03/2008
--------------------------------
Self Reported Allergies
--------------------------------
Source: Self-Entered
Allergy Name: ALLERGENIC EXTRACT, PENICILLIN
Type: Drugs
Reaction: Nausea
Severity: Mild
Diagnosed: Yes
Treatment: Allergy Shots
First Episode Date: 05/01/2007
Allergy Name: Codeine
Type: Drugs
Reaction: Wheezing
Severity: Mild
Diagnosed: Yes
Treatment: Avoidance
First Episode Date: 05/01/2006
Comments:
--------------------------------
Self Reported Implantable Device
--------------------------------
Source: Self-Entered
Device Name: Artificial Eye Lenses
Date Implanted: 1/27/1942
--------------------------------
Self Reported Immunizations
--------------------------------
Source: Self-Entered
Immunization Name: Influenza virus vaccine
Date Administered: 11/01/1999
Method: Intramuscular injection
Immunization Name: Influenza virus vaccine
Date Administered: 12/15/1998
Method: Intramuscular injection
Were you vaccinated in the US:
Comments:
Booster 1 Date:
Booster 2 Date:
Booster 3 Date:
Immunization Name: Pneumococcal polysaccharide vaccine
Date Administered: 12/15/1998
Method: Intramuscular injection
Were you vaccinated in the US:
Comments:
Booster 1 Date:
Booster 2 Date:
Booster 3 Date:
Immunization Name: Tetanus and diphtheria toxoids - preservative free
Date Administered: 12/15/1998
Method: Intramuscular injection
Were you vaccinated in the US:
Comments:
Booster 1 Date:
Booster 2 Date:
Booster 3 Date:
--------------------------------
Self Reported Labs and Tests
--------------------------------
Source: Self-Entered
Test/Lab Type: CBC WO DIFFERENTIAL
Date Taken: 03/23/2000
Administered by: QUEST DIAGNOSTICS
Requesting Doctor: Dr. Smith
Reason Test/Lab Requested:
Results: 13.2, 6.7, 123
Comments: HGB, WBC, PLT
--------------------------------
Self Reported Vital Statistics
--------------------------------
Source: Self-Entered
Vital Statistic Type: Blood Pressure
Date: 11/14/1999
Time: 3:00 PM
Reading: 132/80
Comments: mmHg
Vital Statistic Type: Patient Body Weight - Measured
Date: 11/14/1999
Time: 12:00 PM
Reading: 86
Comments:
Vital Statistic Type: Height
Date: 11/14/1999
Time: 12:00 PM
Reading: 162
Comments: cm
--------------------------------
Family Medical History
--------------------------------
Source: Self-Entered
Family Member: Brother
Type:
DOB:1/10/1915
DOD:
Age:
Type: Allergy
Description: Antiarrythmia
Description: Antibiotic
Description: Anticonvulsants
Type: Condition
Description: Allergies
Description: Alzheimer's Disease
Description: Angina (Heart Pain)
Description: Cataracts
--------------------------------
Drugs
--------------------------------
Source: Self-Entered
Drug Name: Proventil HFA INH 1MG/ACTUAT
Supply: Daily
Orig Drug Entry: Proventil HFA
Drug Name: Aspirin
Supply: Daily
Orig Drug Entry: Aspirin
--------------------------------
Preventive Services
--------------------------------
Source: MyMedicare.gov
Description: DIABETES
Next Eligible Date: 10/1/2011
Last Date of Service:
Description: PAP TEST DR
Next Eligible Date: 10/1/2011
Last Date of Service:
Description: ABDOMINAL AORTIC ANEURYSM
Next Eligible Date: 7/1/2012
Last Date of Service:
Description: ANNUAL WELLNESS VISIT
Next Eligible Date: 1/1/2013
Last Date of Service:
Description: DEPRESSION SCREENING
Next Eligible Date: 10/14/2012
Last Date of Service:
--------------------------------
Providers
--------------------------------
Source: Self-Entered
Provider Name: ANY CARE
Provider Address: 123 Any Rd, Anywhere, MD 99999
Type: NHC
Specialty:
Medicare Provider: Not Available
Provider Name: ANY HOSPITAL1
Provider Address: 123 Drive, Anywhere, VA 00001
Type: HOS
Specialty:
Medicare Provider: Not Available
Provider Name: Jane Doe
Provider Address: 123 Road, Anywhere, VA 00001
Type: PHY
Specialty: Other
Medicare Provider: Not Available
--------------------------------
Pharmacies
--------------------------------
Source: Self-Entered
Pharmacy Name: PHARMACY, EAST STREET ANYWHERE, DC 00002
Pharmacy Phone: 000-000-0001
Pharmacy Name: ANY PHARMACY, WEST STREET ANYWHERE, VA 00001
Pharmacy Phone: 000-000-0002
--------------------------------
Plans
--------------------------------
Source: MyMedicare.gov
Contract ID/Plan ID: H9999/9999
Plan Period: 09/01/2011 - current
Plan Name: Aetna Medicare Value Plan (HMO)
Marketing Name: Aetna Medicare
Plan Address: 123 Any Road Anytown PA 00003
Plan Type: 3 - Coordinated Care Plan (HMO, PPO, PSO, SNP)
Contract ID/Plan ID: S9999/000
Plan Period: 01/01/2010 - current
Plan Name: AARP MedicareRx Saver Plus (PDP)
Marketing Name: UnitedHealthcare
Plan Address: 123 Any Road Anytown PA 00003
Plan Type: 11 - Medicare Prescription Drug Plan
--------------------------------
Employer Subsidy
--------------------------------
Source: MyMedicare.gov
Employer Plan: STATE HEALTH BENEFITS PROGRAM
Employer Subsidy Start Date: 01/01/2011
Employer Subsidy End Date: 12/31/2011
--------------------------------
Claim Summary
--------------------------------
Source: MyMedicare.gov
Claim Number: 4830293857102
Provider: SAFEWAY INC
Provider Billing Address: PO BOX 742382 SAFEWAY INC PHARMACY LOS ANGELES CA 900742382
Service Start Date: 10/09/2013
Service End Date: 10/09/2013
Amount Charged: $57.20
Medicare Approved: $57.20
Provider Paid: $57.20
You May be Billed: $0.00
Claim Type: PartB
Diagnosis Code 1: V0481
--------------------------------
Claim Lines for Claim Number: 4830293857102
--------------------------------
Line number: 1
Date of Service From: 11/01/1999
Date of Service To: 11/01/1999
Procedure Code/Description: 90662 - Vaccine For Influenza For Injection Into Muscle
Modifier 1/Description:
Modifier 2/Description:
Modifier 3/Description:
Modifier 4/Description:
Quantity Billed/Units: 1
Submitted Amount/Charges: $31.90
Allowed Amount: $31.90
Non-Covered: $0.00
Place of Service/Description: 60 - Mass Immunization Center
Type of Service/Description: V - Pneumococcal/Flu Vaccine
Rendering Provider No: PHC011
Rendering Provider NPI: 4839202847
Line number: 2
Date of Service From: 11/01/1999
Date of Service To: 11/01/1999
Procedure Code/Description: G0008 - Administration Of Influenza Virus Vaccine
Modifier 1/Description:
Modifier 2/Description:
Modifier 3/Description:
Modifier 4/Description:
Quantity Billed/Units: 1
Submitted Amount/Charges: $25.30
Allowed Amount: $25.30
Non-Covered: $0.00
Place of Service/Description: 60 - Mass Immunization Center
Type of Service/Description: V - Pneumococcal/Flu Vaccine
Rendering Provider No: PHC011
Rendering Provider NPI: 4839202847
--------------------------------
--------------------------------
Claim Number: 5834920430293
Provider: QUEST DIAGNOSTICS INC MD
Provider Billing Address: 1901 SULPHUR SPRING ROAD BALTIMORE MD 212272997
Service Start Date: 03/23/2000
Service End Date: 03/23/2000
Amount Charged: $308.62
Medicare Approved: $308.62
Provider Paid: $38.89
You May be Billed: $269.73
Claim Type: PartB
Diagnosis Code 1: 2720
Diagnosis Code 2: 4019
--------------------------------
Claim Lines for Claim Number: 5834920430293
--------------------------------
Line number: 1
Date of Service From: 03/23/2000
Date of Service To: 03/23/2000
Procedure Code/Description: 36415 - Insertion Of Needle Into Vein For Collection Of Blood Sample
Modifier 1/Description:
Modifier 2/Description:
Modifier 3/Description:
Modifier 4/Description:
Quantity Billed/Units: 1
Submitted Amount/Charges: $18.87
Allowed Amount: $3.00
Non-Covered: $15.87
Place of Service/Description: 81 - Independent Laboratory
Type of Service/Description: 5 - Diagnostic Lab
Rendering Provider No: W520
Rendering Provider NPI: 5493844123
Line number: 2
Date of Service From: 03/23/2000
Date of Service To: 03/23/2000
Procedure Code/Description: 80053 - Blood Test, Comprehensive Group Of Blood Chemicals
Modifier 1/Description: QP - Documentation Is On File Showing That The Laboratory Test(S) Was Ordered Individually Or Ordere
Modifier 2/Description:
Modifier 3/Description:
Modifier 4/Description:
Quantity Billed/Units: 1
Submitted Amount/Charges: $80.98
Allowed Amount: $8.84
Non-Covered: $72.14
Place of Service/Description: 81 - Independent Laboratory
Type of Service/Description: 5 - Diagnostic Lab
Rendering Provider No: W520
Rendering Provider NPI: 5493844123
Line number: 3
Date of Service From: 03/23/2000
Date of Service To: 03/23/2000
Procedure Code/Description: 80061 - Blood Test, Lipids (Cholesterol And Triglycerides)
Modifier 1/Description:
Modifier 2/Description:
Modifier 3/Description:
Modifier 4/Description:
Quantity Billed/Units: 1
Submitted Amount/Charges: $146.80
Allowed Amount: $16.03
Non-Covered: $130.77
Place of Service/Description: 81 - Independent Laboratory
Type of Service/Description: 5 - Diagnostic Lab
Rendering Provider No: W520
Rendering Provider NPI: 5493844123
Line number: 4
Date of Service From: 03/23/2000
Date of Service To: 03/23/2000
Procedure Code/Description: 85025 - Complete Blood Cell Count (Red Cells, White Blood Cell, Platelets), Automated Test
Modifier 1/Description:
Modifier 2/Description:
Modifier 3/Description:
Modifier 4/Description:
Quantity Billed/Units: 1
Submitted Amount/Charges: $61.97
Allowed Amount: $11.02
Non-Covered: $50.95
Place of Service/Description: 81 - Independent Laboratory
Type of Service/Description: 5 - Diagnostic Lab
Rendering Provider No: W520
Rendering Provider NPI: 5493844123
--------------------------------