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I <br /> <br />IPATIENT <br /> <br />P.O. BO~ 9408 <br />WINhTEAPOL I S, MN <br /> <br />ADMISSION 'nME <br /> <br />LAST NAME <br /> <br />BUCHITE <br /> <br />AD. ESS (5tr~ ~. C~. Stale, ~p Coc~) <br /> <br /> PO BOX <br /> <br />IINSURED <br /> (POUCY HOLDERI <br /> <br />LAST NAME <br /> <br /> PATIL~IT <br /> <br />rEMPLOYER. UNION NAME OR LOCAL <br /> <br />5 5&~,0 61 ?-786-2200 <br /> INSURANCE CLAIM FORM <br /> IDA'rE I PATIENT HOSP~AL NO. <br /> 08-06-8a; 909656-1 <br /> <br /> RICHARD H I ~,7&- 1 8~-8/., 9- X tM <br /> J TELEPHONE NO <br /> <br /> ELK RIVER MN S$330J <br /> FIRST MI J SOCIAL SECURITY NO. J IB{RTH DATE <br /> I <br /> I <br /> <br /> JMAR~'IAL STATUS <br /> <br /> :4AR R,[ Eb <br /> J BIRTH DATE <br /> <br />4~.1-41~6 J ~4-1R-1 <br /> <br />CITY OF RAIVSEY <br /> <br />OR · NAME <br /> <br /> CIIT OF <br /> SECONDARY PAYORS - NAMES <br /> <br />~LL TO' <br /> <br />~SEY <br /> <br />INSURED'$ NAME & RELATIONSHIP TO PATIENT <br /> <br /> PATIEHT I <br /> <br />INSURED'S NAME & RELATIONSHIP TO PATIENT <br /> <br />· CITY OF RAI~EY <br />· ltO~,/'rH]ZN BLt/Do <br />· AblOF,.A, ~o 55303 <br /> <br /> DESO~IP.nON <br /> <br />RADIOLOGY <br /> <br /> I ~LAIM C~R.nFICATE - mD NO. IHIC) <br /> <br /> WOP,.KAttI.I C~4P <br /> ~M ~R~TE - ~ NO. (HIC) <br /> <br /> I <br /> ~IMARY ~GNOSIS: J <br /> COOE J Ct L, <br /> CODE <br /> <br />TOT~ C~RGES RE~: <br />~ 6 5 . g 0 ~IS ADMISSION DUE TO ~ ACCIDE~ <br />j AC~ ~ <br /> LIFTI~ <br />j A~m L~ <br /> ,~ ~o~ <br /> j A~ DA~ J H~R <br /> ~T, 81 J unkn~n <br /> I ~ OF C~M: ~ WORK COM~ <br /> <br />GROUP NAME - NO. <br />GROUP NAME. NO. <br /> <br />SPINEt R/O IIIVD <br /> <br />YESZ~) NO ( I <br /> <br />)GROUP <br /> <br />08-04-83 <br /> <br /> ( ) INDIVIDUAL ( ) AUTO <br /> . q :.:., <br /> <br /> I <br /> 08-08'- 83 991 <br /> I <br /> EIILL FROM 08-04-83 10 <br /> <br /> I <br /> DOCTOR-' LAI~.CHARLES <br /> <br /> · I <br /> <br /> ~~IF PATIENT HAD OTHER THAN SE~I-PRIVATE ROO.M,, INDICATE SEMI-PRIVATE DAILY RATE $ J~~ ~J <br /> ......................................................................... ~ ............ ;~1 <br /> ~ AUTHORIZATION SIGNATURE IS ON FILE. BENEFITS HAVE BEEN PROPERLY ASSIGNED TO: ' <br />! . <br /> <br /> ! <br /> <br />UNITY I~EOICAL CENTER <br /> <br />A VALID RELEASE AUTHORIZATION SIGNATURE IS ON RLE. THIS RELEASE IS IN COMPLIANCE WITH ALL CURRENT <br />REGULATIONS CONCERNING RELEASE OF MEDICAL RECORDS. <br /> <br />I CERTIFY THAT THE CERTIFICATIONS APPLY TO <br />THIS BILL AND ARE MADE A PART HEREOF: X A P <br /> PROVIDER REPRESENTATIVE <br /> <br />o8-3o-83J <br /> <br /> <br />