                          VSS Medical Office System                       (52D)
Account#:        1      +--------------------------+            Date: 02/24/03
                        | Patient Demographic Data |
                        +--------------------------+
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|   Name: Ms. Helena M Adells               Date of Birth: 10/04/1912 Age:  90 |
|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             |
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  Important NOTES                   Physician: 1     Vicki G Henry M.D.
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+------------------------------------------------------------------------------+
| Employed: F                           Student: F                             |
| Employer/School WEST     Westinghouse Beatice                                |
| Occupation:                            Phone #:                  Ext:        |
| WC Company: AR1   Ar1                                                        |
| Policy: 678898              Group: 12345                                     |
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     Send Statements to:
    +-----------------------------------------------------------------------+
    | P       1  Helena M Adells                 Relationship: Self         |
    +-----------------------------------------------------------------------+
 Referred By:
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| Other than M.D.:                                                             |
|            M.D.: VCS                                                         |
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     Insurance Information:
    +-----------------------------------------------------------------------+
    | Company MC      Medicare                      Policy: 123456789A      |
    |                                                Group:                 |
    | Policy Holder:                                                        |
    | Name: R       8  Adam L Kuczma             Relationship: 01  Sex:M    |
    +-----------------------------------------------------------------------+
    | Company BS      BLUE SHIELD Of Kentucky       Policy: 183385467B      |
    |                                                Group: 6609000         |
    | Policy Holder:                                                        |
    | Name: P       1  Helena M Adells           Relationship: 01  Sex:F    |
    +-----------------------------------------------------------------------+
    | Company MD      Medicaid                      Policy:                 |
    |                                                Group:                 |
    | Policy Holder:                                                        |
    | Name: P       1  Helena M Adells           Relationship: 01  Sex:F    |
    +-----------------------------------------------------------------------+
+----------------------------------+-------------+--------------+--------------+
| Assignment: Y  NOT DUNNING PATIE | Dunning: N  | Status: A    | Inv Age:  0  |
+---------------------+------------+-------------+--------------+--------------+
|   Balance Due       |  Pat Since: 10/07/83           Tot Chg:  4854.50       |
|                     |  Last Paid: 03/07/02                       60.00       |
|Insurance:    87.40  | Last W/OFF: 03/07/02                         .00       |
|  Patient:   113.60  |  Statement: 02/20/02                      420.93       |
|Total due:   201.00  |  Insurance: MC    BS    MD     AR1                     |
|                     |  Last Recap: 013003           Last DX                  |
|                     |  NOTES      Medicare Primary            1              |
+---------------------+--------------------------------------------------------+
|Last Visit: 03/07/2002  Next Appnt: 01/31/2003  8:30      AM     With: 1      |
|                                                                              |
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