-------------------------------- 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: isabella@amida.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: 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: 177 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 --------------------------------