                          VSS Medical Office System                       (52A)
Account#:        1      +--------------------------+            Date: 01/11/06
                        | Patient Demographic Data |
                        +--------------------------+
+------------------------------------------------------------------------------+
|   Name: Ms. Helena M Adells               Date of Birth: 10/04/1912 Age:  93 |
|Address: 556 Shady Grove                         Sex: F   Marital: U          |
|Address:                                         Soc. Sec. #: 555-38-5467     |
|   City: Pittsburgh      State: PA  Zip: 15220                                |
| Patient Since: 10/07/83             Home Phone #: (412) 835-9415             |
+------------------------------------------------------------------------------+
  Important NOTES                   Physician: 1     Vicki G Henry M.D.
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THIS IS NOW ALL THING SNOW I CANS THIS IS THE STUFF THIS
HELLO THERE NOW YOU CAN SEE ITS  YOU CAN ONLY SEE THESE THIS
NOW WHEN YOU ARE HERE THIS THIS                                        TEST
CAN NOT NOW YOU CAN NOT SEE THEM IS
<PTPAY>57.45</PTPAY>   YOUR BRAIN IS SILLYA
WHEN I SAY THREE HOLD YOUR BREATH AND COUNT TO A MILLION THEN YOU CAN STOP.
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| Employed: F                           Student: F                             |
| Employer/School WEST     Westinghouse Beatice                                |
| Occupation:                            Phone #: (412) 835-9417   Ext:    111 |
|                                                                              |
| WC Company: _AR1  American Retired Persons                                   |
| Policy: 9291733             Group: 2902929                                   |
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     Send Statements to:
    +-----------------------------------------------------------------------+
    | P       1  Helena M Adells                 Relationship:              |
    +-----------------------------------------------------------------------+
 Referred By:
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| Other than M.D.:                                                             |
|            M.D.:                                                             |
+------------------------------------------------------------------------------+
     Insurance Information:
    +-----------------------------------------------------------------------+
    | Company MC      Medicare                      Policy: 234290293A      |
    |                                                Group:                 |
    | Policy Holder:                                                        |
    | Name: P       1  Helena M Adells           Relationship: 03  Sex:F    |
    +-----------------------------------------------------------------------+
    | Company BS      BLUE SHIELD Of Kentucky       Policy: 183385467B      |
    |                                                Group: 6609000         |
    | Policy Holder:                                                        |
    | Name: R      27  Nancy Palmquist           Relationship: 03  Sex:F    |
    +-----------------------------------------------------------------------+
    | Company AARP    Retired People Insurance      Policy: 111223333       |
    |                                                Group: 29434           |
    | Policy Holder:                                                        |
    | Name: R      28  Big All                   Relationship: 01  Sex:F    |
    +-----------------------------------------------------------------------+
+----------------------------------+-------------+--------------+--------------+
| Assignment: Y  NOT DUNNING PATIE | Dunning: N  | Status: A    |              |
+-------------------------+--------+-------------+--------------+--------------+
|  Pat Since: 10/07/83    |   Insurance: MC    BS    AARP   _AR1               |
|  Last Paid: 01/11/06    |   Last Recap:                  Last DX             |
| Last W/OFF: 10/12/05    |   NOTES      Medicare Primary            6         |
|  Statement: 03/11/05    |                                                    |
|                         |                                                    |
+-------------------------+----------------------------------------------------+
|Last Visit: 01/11/2006  Next Appnt:                               With:       |
|                                                                              |
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