-------------------------------- MYMEDICARE.GOV PERSONAL HEALTH INFORMATION -------------------------------- **********CONFIDENTIAL*********** Produced by the Blue Button (v2.0) 03/16/2013 5:10 AM -------------------------------- Demographic -------------------------------- Source: MyMedicare.gov Name: JOHN DOE Date of Birth: 01/01/1910 Address Line 1: 123 ANY ROAD Address Line 2: City: ANYTOWN State: VA Zip: 00001 Phone Number: 123-456-7890 Email: JOHNDOE@example.com 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: JANEDOE@example.com 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: STEVEDOE@example.com -------------------------------- Self Reported Medical Conditions -------------------------------- Source: Self-Entered Condition Name: Arthritis Medical Condition Start Date: 08/09/2005 Medical Condition End Date: 02/28/2011 Condition Name: Asthma Medical Condition Start Date: 01/25/2008 Medical Condition End Date: 01/25/2010 -------------------------------- Self Reported Allergies -------------------------------- Source: Self-Entered Allergy Name: Antibotic Type: Drugs Reaction: Vomiting Severity: Severe Diagnosed: Yes Treatment: Allergy Shots First Episode Date: 01/08/1926 Last Episode Date: 03/13/1955 Last Treatment Date: 09/28/1949 Comments: Erythromycin Allergy Name: Grasses Type: Environmental Reaction: Sneezing Severity: Severe Diagnosed: Yes Treatment: Avoidance First Episode Date: 05/13/1973 Last Episode Date: 07/20/1996 Last Treatment Date: 09/27/2008 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: Varicella/Chicken Pox Date Administered:04/21/2002 Method: Nasal Spray(mist) Were you vaccinated in the US: Comments: congestion Booster 1 Date: 02/02/1990 Booster 2 Date: Booster 3 Date: Immunization Name: typhoid Date Administered:01/02/2009 Method: 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: Glucose Level Date Taken: 03/21/2008 Administered by: AnyLab Requesting Doctor: Dr. Smith Reason Test/Lab Requested: Ongoing elevated glucose Results: 135, 170, 150, 120 Comments: Fasting, hour 1, hour 2, hour 3 -------------------------------- Self Reported Vital Statistics -------------------------------- Source: Self-Entered Vital Statistic Type: Blood Pressure Date: 07/22/2011 Time: 3:00 PM Reading: 120/80 Comments: Vital Statistic Type: Glucose Date: 03/20/2012 Time: 12:00 PM Reading: 110 Comments: -------------------------------- 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: Aspirin Supply: Dialy 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: A Medicare Plan Plus (HMO) Marketing Name: HealthCare Payer 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: A Medicare Rx Plan (PDP) Marketing Name: Another HealthCare Payer 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 -------------------------------- Primary Insurance -------------------------------- Source: MyMedicare.gov MSP Type: End stage Renal Disease (ESRD) Policy Number: 1234567890 Insurer Name: Insurer1 Insurer Address: PO BOX 0000 Anytown, CO 00002-0000 Effective Date: 01/01/2011 Termination Date: 09/30/2011 MSP Type: End stage Renal Disease (ESRD) Policy Number: 12345678901 Insurer Name: Insurer2 Insurer Address: 0000 Any ROAD ANYWHERE, VA 00000-0000 Effective Date: 01/01/2010 Termination Date: 12/31/2010 -------------------------------- Other Insurance -------------------------------- Source: MyMedicare.gov MSP Type: Policy Number: 00001 Insurer Name: Insurer Insurer Address: 00 Address STREET ANYWHERE, PA 00000 Effective Date: 10/01/1984 Termination Date: 11/30/2008 -------------------------------- Claim Summary -------------------------------- Source: MyMedicare.gov Claim Number: 1234567890000 Provider: No Information Available Provider Billing Address: Service Start Date: 10/18/2012 Service End Date: Amount Charged: $60.00 Medicare Approved: $34.00 Provider Paid: $27.20 You May be Billed: $6.80 Claim Type: PartB Diagnosis Code 1: 3534 Diagnosis Code 2: 7393 Diagnosis Code 3: 7392 Diagnosis Code 4: 3533 -------------------------------- Claim Lines for Claim Number: 1234567890000 -------------------------------- Line number: 1 Date of Service From: 10/18/2012 Date of Service To: 10/18/2012 Procedure Code/Description: 98941 - Chiropractic Manipulative Treatment (Cmt); Spinal, Three To Four Regions Modifier 1/Description: AT - Acute Treatment (This Modifier Should Be Used When Reporting Service 98940, 98941, 98942) Modifier 2/Description: Modifier 3/Description: Modifier 4/Description: Quantity Billed/Units: 1 Submitted Amount/Charges: $60.00 Allowed Amount: $34.00 Non-Covered: $26.00 Place of Service/Description: 11 - Office Type of Service/Description: 1 - Medical Care Rendering Provider No: 0000001 Rendering Provider NPI: 123456789 -------------------------------- -------------------------------- Claim Number: 12345678900000VAA Provider: No Information Available Provider Billing Address: Service Start Date: 09/22/2012 Service End Date: Amount Charged: $504.80 Medicare Approved: $504.80 Provider Paid: $126.31 You May be Billed: $38.84 Claim Type: Outpatient Diagnosis Code 1: 56400 Diagnosis Code 2: 7245 Diagnosis Code 3: V1588 -------------------------------- Claim Lines for Claim Number: 12345678900000VAA -------------------------------- Line number: 1 Date of Service From: 09/22/2012 Revenue Code/Description: 0250 - General Classification PHARMACY Procedure Code/Description: Modifier 1/Description: Modifier 2/Description: Modifier 3/Description: Modifier 4/Description: Quantity Billed/Units: 1 Submitted Amount/Charges: $14.30 Allowed Amount: $14.30 Non-Covered: $0.00 Line number: 2 Date of Service From: 09/22/2012 Revenue Code/Description: 0320 - General Classification DX X-RAY Procedure Code/Description: 74020 - Radiologic Examination, Abdomen; Complete, Including Decubitus And/Or Erect Views Modifier 1/Description: Modifier 2/Description: Modifier 3/Description: Modifier 4/Description: Quantity Billed/Units: 1 Submitted Amount/Charges: $175.50 Allowed Amount: $175.50 Non-Covered: $0.00 Line number: 3 Date of Service From: 09/22/2012 Revenue Code/Description: 0450 - General Classification EMERG ROOM Procedure Code/Description: 99283 - Emergency Department Visit For The Evaluation And Management Of A Patient, Which Requires Th Modifier 1/Description: 25 - Significant, Separately Identifiable Evaluation And Management Service By The Same Physician On Modifier 2/Description: Modifier 3/Description: Modifier 4/Description: Quantity Billed/Units: 1 Submitted Amount/Charges: $315.00 Allowed Amount: $315.00 Non-Covered: $0.00 Line number: 4 Date of Service From: Revenue Code/Description: 0001 - Total Charges Procedure Code/Description: Modifier 1/Description: Modifier 2/Description: Modifier 3/Description: Modifier 4/Description: Quantity Billed/Units: 0 Submitted Amount/Charges: $504.80 Allowed Amount: $504.80 Non-Covered: $0.00 Claim Number: 1234567890123 Provider: No Information Available Provider Billing Address: Service Start Date: 12/01/2012 Service End Date: Amount Charged: * Not Available * Medicare Approved: * Not Available * Provider Paid: * Not Available * You May be Billed: * Not Available * Claim Type: PartB Diagnosis Code 1: 7392 Diagnosis Code 2: 7241 Diagnosis Code 3: 7393 Diagnosis Code 4: 7391 -------------------------------- Claim Lines for Claim Number: 1234567890123 -------------------------------- Line number: 1 Date of Service From: 12/01/2012 Date of Service To: 12/01/2012 Procedure Code/Description: 98941 - Chiropractic Manipulative Treatment, 3 To 4 Spinal Regions Modifier 1/Description: GA - Waiver Of Liability Statement Issued As Required By Payer Policy, Individual Case Modifier 2/Description: Modifier 3/Description: Modifier 4/Description: Quantity Billed/Units: 1 Submitted Amount/Charges: * Not Available * Allowed Amount: * Not Available * Non-Covered: * Not Available * Place of Service/Description: 11 - Office Type of Service/Description: 1 - Medical Care Rendering Provider No: 123456 Rendering Provider NPI: 123456789 Line number: 2 Date of Service From: 12/01/2012 Date of Service To: 12/01/2012 Procedure Code/Description: G0283 - Electrical Stimulation (Unattended), To One Or More Areas For Indication(S) Other Than Wound Modifier 1/Description: GY - Item Or Service Statutorily Excluded, Does Not Meet The Definition Of Any Medicare Benefit Or, Modifier 2/Description: Modifier 3/Description: Modifier 4/Description: Quantity Billed/Units: 1 Submitted Amount/Charges: * Not Available * Allowed Amount: * Not Available * Non-Covered: * Not Available * Place of Service/Description: 11 - Office Type of Service/Description: 1 - Medical Care Rendering Provider No: 123456 Rendering Provider NPI: 123456789 -------------------------------- Claim Lines for Claim Number: 123456789012 -------------------------------- Claim Type: Part D Claim Number: 123456789012 Claim Service Date: 11/17/2011 Pharmacy / Service Provider: 123456789 Pharmacy Name: PHARMACY2 #00000 Drug Code: 00093013505 Drug Name: CARVEDILOL Fill Number: 0 Days' Supply: 30 Prescriber Identifer: 123456789 Prescriber Name: Jane Doe -------------------------------- Claim Lines for Claim Number: 123456789011 -------------------------------- Claim Type: Part D Claim Number: 123456789011 Claim Service Date: 11/23/2011 Pharmacy / Service Provider: 1234567890 Pharmacy Name: PHARMACY3 #00000 Drug Code: 00781223310 Drug Name: OMEPRAZOLE Fill Number: 4 Days' Supply: 30 Prescriber Identifer: 123456789 Prescriber Name: Jane Doe --------------------------------