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June 21, 2010 20:50
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<demographics> | |
<id>demo.2010-01-14.6557744442</id> | |
<title>Demographics</title> | |
<subject> | |
</subject> | |
<description> | |
</description> | |
<contributors> | |
</contributors> | |
<creators> | |
</creators> | |
<effectivedate> | |
</effectivedate> | |
<expirationdate> | |
</expirationdate> | |
<language> | |
</language> | |
<rights> | |
</rights> | |
<creation_date>2010/01/14 16:50:56.006 US/Pacific</creation_date> | |
<modification_date>2010/05/11 16:33:32.270 GMT-7</modification_date> | |
<intake>2010/01/14</intake> | |
<last>Test</last> | |
<first>User</first> | |
<middle> | |
</middle> | |
<nickname> | |
</nickname> | |
<address> | |
</address> | |
<city> | |
</city> | |
<county> | |
</county> | |
<state> | |
</state> | |
<zip> | |
</zip> | |
<lat_long> | |
</lat_long> | |
<mail_to> | |
</mail_to> | |
<mail_address> | |
</mail_address> | |
<mail_city> | |
</mail_city> | |
<mail_state> | |
</mail_state> | |
<mail_zip> | |
</mail_zip> | |
<phone_number> | |
</phone_number> | |
<alt_phone_number> | |
</alt_phone_number> | |
<ssn> | |
</ssn> | |
<dob> | |
</dob> | |
<sex> | |
</sex> | |
<alone> | |
</alone> | |
<cross_street> | |
</cross_street> | |
<facility_name> | |
</facility_name> | |
<caller> | |
</caller> | |
<caller_num> | |
</caller_num> | |
<caller_relation> | |
</caller_relation> | |
<loc_type>Home</loc_type> | |
<janus_id>DEMO_1195</janus_id> | |
<alternate_id> | |
</alternate_id> | |
<alerts> | |
</alerts> | |
<otheralert> | |
</otheralert> | |
<patient_status>Current</patient_status> | |
<reason_for_discharge> | |
</reason_for_discharge> | |
<date_of_death> | |
</date_of_death> | |
<directives> | |
</directives> | |
<allergies> | |
</allergies> | |
<noknownallergies> | |
</noknownallergies> | |
<disposition> | |
</disposition> | |
<pharmacy> | |
</pharmacy> | |
<pharmacy_num> | |
</pharmacy_num> | |
<pharmacy_fax> | |
</pharmacy_fax> | |
<home_health> | |
</home_health> | |
<home_health_contact> | |
</home_health_contact> | |
<home_health_num> | |
</home_health_num> | |
<home_health_fax> | |
</home_health_fax> | |
<map_page> | |
</map_page> | |
<clinician_name>demo1</clinician_name> | |
<last_checkup> | |
</last_checkup> | |
<last_hospitalization> | |
</last_hospitalization> | |
<known_diagnoses> | |
</known_diagnoses> | |
<other_known_diagnoses> | |
</other_known_diagnoses> | |
<midlevel_name> | |
</midlevel_name> | |
<chief_complaint> | |
</chief_complaint> | |
<treatment_days> | |
</treatment_days> | |
<treatment_type> | |
</treatment_type> | |
<dispatchers_notes> | |
</dispatchers_notes> | |
<primary_type>Commercial</primary_type> | |
<primary_carrier_code> | |
</primary_carrier_code> | |
<primary_carrier>dsfdfsd</primary_carrier> | |
<primary_policy_holder_relationship>1</primary_policy_holder_relationship> | |
<primary_policy_holder_name> | |
</primary_policy_holder_name> | |
<primary_certificate_num>sfsdfsdf</primary_certificate_num> | |
<primary_group_num> | |
</primary_group_num> | |
<primary_addr1> | |
</primary_addr1> | |
<primary_city> | |
</primary_city> | |
<primary_st> | |
</primary_st> | |
<primary_zip> | |
</primary_zip> | |
<primary_phone> | |
</primary_phone> | |
<p_part_b_verified> | |
</p_part_b_verified> | |
<p_effective_date> | |
</p_effective_date> | |
<p_end_date> | |
</p_end_date> | |
<primary_current_deduct_p> | |
</primary_current_deduct_p> | |
<primary_prior_deduct_p> | |
</primary_prior_deduct_p> | |
<primary_notes> | |
</primary_notes> | |
<primary_primary> | |
</primary_primary> | |
<primary_medicare_contact> | |
</primary_medicare_contact> | |
<secondary_type> | |
</secondary_type> | |
<secondary_carrier_code> | |
</secondary_carrier_code> | |
<secondary_carrier> | |
</secondary_carrier> | |
<secondary_policy_holder_relationship>1</secondary_policy_holder_relationship> | |
<secondary_policy_holder_name> | |
</secondary_policy_holder_name> | |
<secondary_certificate_num> | |
</secondary_certificate_num> | |
<secondary_group_num> | |
</secondary_group_num> | |
<secondary_addr1> | |
</secondary_addr1> | |
<secondary_city> | |
</secondary_city> | |
<secondary_st> | |
</secondary_st> | |
<secondary_zip> | |
</secondary_zip> | |
<secondary_phone> | |
</secondary_phone> | |
<s_part_b_verified> | |
</s_part_b_verified> | |
<s_effective_date> | |
</s_effective_date> | |
<s_end_date> | |
</s_end_date> | |
<secondary_current_deduct_p> | |
</secondary_current_deduct_p> | |
<secondary_prior_deduct_p> | |
</secondary_prior_deduct_p> | |
<secondary_notes> | |
</secondary_notes> | |
<secondary_primary> | |
</secondary_primary> | |
<secondary_medicare_contact> | |
</secondary_medicare_contact> | |
<tertiary_type> | |
</tertiary_type> | |
<tertiary_carrier_code> | |
</tertiary_carrier_code> | |
<tertiary_carrier> | |
</tertiary_carrier> | |
<tertiary_policy_holder_relationship>1</tertiary_policy_holder_relationship> | |
<tertiary_policy_holder_name> | |
</tertiary_policy_holder_name> | |
<tertiary_certificate_num> | |
</tertiary_certificate_num> | |
<tertiary_group_num> | |
</tertiary_group_num> | |
<tertiary_addr1> | |
</tertiary_addr1> | |
<tertiary_city> | |
</tertiary_city> | |
<tertiary_st> | |
</tertiary_st> | |
<tertiary_zip> | |
</tertiary_zip> | |
<tertiary_phone> | |
</tertiary_phone> | |
<t_part_b_verified> | |
</t_part_b_verified> | |
<t_effective_date> | |
</t_effective_date> | |
<t_end_date> | |
</t_end_date> | |
<tertiary_current_deduct_p> | |
</tertiary_current_deduct_p> | |
<tertiary_prior_deduct_p> | |
</tertiary_prior_deduct_p> | |
<tertiary_notes> | |
</tertiary_notes> | |
<tertiary_primary> | |
</tertiary_primary> | |
<tertiary_medicare_contact> | |
</tertiary_medicare_contact> | |
<caller_type> | |
</caller_type> | |
<caller_info> | |
</caller_info> | |
<how_hear> | |
</how_hear> | |
<how_hear_info> | |
</how_hear_info> | |
<guarantor_type> | |
</guarantor_type> | |
<guarantor_name> | |
</guarantor_name> | |
<guarantor_phone_home> | |
</guarantor_phone_home> | |
<guarantor_phone_cell> | |
</guarantor_phone_cell> | |
<guarantor_phone_work> | |
</guarantor_phone_work> | |
<guarantor_addr> | |
</guarantor_addr> | |
<guarantor_city> | |
</guarantor_city> | |
<guarantor_state> | |
</guarantor_state> | |
<guarantor_zip> | |
</guarantor_zip> | |
<ec_name> | |
</ec_name> | |
<ec_phone> | |
</ec_phone> | |
<ec_wphone> | |
</ec_wphone> | |
<ec_cphone> | |
</ec_cphone> | |
<ec_relation> | |
</ec_relation> | |
<ec_addr> | |
</ec_addr> | |
<ec_city> | |
</ec_city> | |
<ec_state> | |
</ec_state> | |
<ec_zip> | |
</ec_zip> | |
<ec_other> | |
</ec_other> | |
<ec2_name> | |
</ec2_name> | |
<ec2_phone> | |
</ec2_phone> | |
<ec2_wphone> | |
</ec2_wphone> | |
<ec2_cphone> | |
</ec2_cphone> | |
<ec2_relation> | |
</ec2_relation> | |
<ec2_addr> | |
</ec2_addr> | |
<ec2_city> | |
</ec2_city> | |
<ec2_state> | |
</ec2_state> | |
<ec2_zip> | |
</ec2_zip> | |
<ec2_other> | |
</ec2_other> | |
<pcp_name> | |
</pcp_name> | |
<pcp_phone> | |
</pcp_phone> | |
<pcp_upin> | |
</pcp_upin> | |
<pcp_npi> | |
</pcp_npi> | |
<pcp_request> | |
</pcp_request> | |
<cc_name> | |
</cc_name> | |
<cc_other_auth> | |
</cc_other_auth> | |
<cc_today> | |
</cc_today> | |
<cc_type> | |
</cc_type> | |
<cc_number> | |
</cc_number> | |
<cc_sec_code> | |
</cc_sec_code> | |
<cc_exp> | |
</cc_exp> | |
<legend> | |
<id>Short Name</id> | |
<title>Title</title> | |
<subject>Keywords</subject> | |
<description>Description</description> | |
<contributors>Contributors</contributors> | |
<creators>Creators</creators> | |
<effectiveDate>Effective Date</effectiveDate> | |
<expirationDate>Expiration Date</expirationDate> | |
<language>Language</language> | |
<rights>Copyrights</rights> | |
<creation_date>Creation Date</creation_date> | |
<modification_date>Modification Date</modification_date> | |
<intake>Intake Date</intake> | |
<last>Last Name</last> | |
<first>First Name</first> | |
<middle>Middle Name</middle> | |
<nickname>Nick Name</nickname> | |
<address>Street Address</address> | |
<city>City</city> | |
<county>County</county> | |
<state>State</state> | |
<zip>Zip</zip> | |
<lat_long>Lat_long</lat_long> | |
<mail_to>Address Mail to</mail_to> | |
<mail_address>Mailing Street Address</mail_address> | |
<mail_city>Mailing City</mail_city> | |
<mail_state>Mailing State</mail_state> | |
<mail_zip>Mailing Zip</mail_zip> | |
<phone_number>Phone</phone_number> | |
<alt_phone_number>Alternate Phone</alt_phone_number> | |
<SSN>SSN</SSN> | |
<DOB>Date of birth</DOB> | |
<Sex>Sex</Sex> | |
<alone>Patient lives alone?</alone> | |
<cross_street>Cross Street</cross_street> | |
<facility_name>Facility Name</facility_name> | |
<caller>Caller - Referral Source</caller> | |
<caller_num>Caller's Phone #</caller_num> | |
<caller_relation>Relationship to Patient</caller_relation> | |
<loc_type>Location Type</loc_type> | |
<janus_id>Janus ID</janus_id> | |
<alternate_id>Alternate Patient ID</alternate_id> | |
<alerts>Alerts</alerts> | |
<otherAlert>Other Alert</otherAlert> | |
<patient_status>Patient Status</patient_status> | |
<reason_for_discharge>Reason for Discharge</reason_for_discharge> | |
<date_of_death>Date of Death</date_of_death> | |
<directives>Consents and Advanced Directives</directives> | |
<allergies>Please describe any allergies and adverse reactions</allergies> | |
<noKnownAllergies>No known drug allergies</noKnownAllergies> | |
<disposition>Disposition</disposition> | |
<pharmacy>Pharmacy</pharmacy> | |
<pharmacy_num>Pharmacy Phone</pharmacy_num> | |
<pharmacy_fax>Pharmacy Fax</pharmacy_fax> | |
<home_health>Home Health Agency</home_health> | |
<home_health_contact>Home Health Contact</home_health_contact> | |
<home_health_num>Home Health Phone</home_health_num> | |
<home_health_fax>Home Health Fax</home_health_fax> | |
<map_page>Map page</map_page> | |
<clinician_name>Physician Name</clinician_name> | |
<last_checkup>Last Physician Checkup</last_checkup> | |
<last_hospitalization>Last Hospitalization</last_hospitalization> | |
<known_diagnoses>Known Diagnoses</known_diagnoses> | |
<other_known_diagnoses>Other Known Diagnoses</other_known_diagnoses> | |
<midlevel_name>Non-Physician Practitioner Name</midlevel_name> | |
<chief_complaint>Initial Complaint</chief_complaint> | |
<treatment_days>Treatment Days</treatment_days> | |
<treatment_type>Type of Treatment</treatment_type> | |
<dispatchers_notes>Dispatcher Notes</dispatchers_notes> | |
<primary_type>Primary Coverage Type</primary_type> | |
<primary_carrier_code>Primary Insurance Carrier</primary_carrier_code> | |
<primary_carrier>Carrier Name</primary_carrier> | |
<primary_policy_holder_relationship>Policy Holder</primary_policy_holder_relationship> | |
<primary_policy_holder_name>Policy Holder Name</primary_policy_holder_name> | |
<primary_certificate_num>Certificate #</primary_certificate_num> | |
<primary_group_num>Group #</primary_group_num> | |
<primary_addr1>Mailing Address</primary_addr1> | |
<primary_city>City</primary_city> | |
<primary_st>State</primary_st> | |
<primary_zip>Zip</primary_zip> | |
<primary_phone>Phone Number</primary_phone> | |
<p_part_b_verified>Verification</p_part_b_verified> | |
<p_effective_date>Effective Date</p_effective_date> | |
<p_end_date>End Date</p_end_date> | |
<primary_current_deduct_p>Deductible Met (Current Year)</primary_current_deduct_p> | |
<primary_prior_deduct_p>Deductible Met (Prior Year)</primary_prior_deduct_p> | |
<primary_notes>Primary Insurance Notes</primary_notes> | |
<primary_primary>Primary</primary_primary> | |
<primary_medicare_contact>Medicare Contact</primary_medicare_contact> | |
<secondary_type>Coverage Type</secondary_type> | |
<secondary_carrier_code>Insurance Carrier</secondary_carrier_code> | |
<secondary_carrier>Carrier Name</secondary_carrier> | |
<secondary_policy_holder_relationship>Policy Holder</secondary_policy_holder_relationship> | |
<secondary_policy_holder_name>Policy Holder Name</secondary_policy_holder_name> | |
<secondary_certificate_num>Certificate #</secondary_certificate_num> | |
<secondary_group_num>Group #</secondary_group_num> | |
<secondary_addr1>Mailing Address</secondary_addr1> | |
<secondary_city>City</secondary_city> | |
<secondary_st>State</secondary_st> | |
<secondary_zip>Zip</secondary_zip> | |
<secondary_phone>Phone Number</secondary_phone> | |
<s_part_b_verified>Verification</s_part_b_verified> | |
<s_effective_date>Effective Date</s_effective_date> | |
<s_end_date>End Date</s_end_date> | |
<secondary_current_deduct_p>Deductible Met (Current Year)</secondary_current_deduct_p> | |
<secondary_prior_deduct_p>Deductible Met (Prior Year)</secondary_prior_deduct_p> | |
<secondary_notes>Secondary Insurance Notes</secondary_notes> | |
<secondary_primary>Primary</secondary_primary> | |
<secondary_medicare_contact>Medicare Contact</secondary_medicare_contact> | |
<tertiary_type>Coverage Type</tertiary_type> | |
<tertiary_carrier_code>Insurance Carrier</tertiary_carrier_code> | |
<tertiary_carrier>Carrier Name</tertiary_carrier> | |
<tertiary_policy_holder_relationship>Policy Holder</tertiary_policy_holder_relationship> | |
<tertiary_policy_holder_name>Policy Holder Name</tertiary_policy_holder_name> | |
<tertiary_certificate_num>Certificate #</tertiary_certificate_num> | |
<tertiary_group_num>Group #</tertiary_group_num> | |
<tertiary_addr1>Mailing Address</tertiary_addr1> | |
<tertiary_city>City</tertiary_city> | |
<tertiary_st>State</tertiary_st> | |
<tertiary_zip>Zip</tertiary_zip> | |
<tertiary_phone>Phone Number</tertiary_phone> | |
<t_part_b_verified>Verification</t_part_b_verified> | |
<t_effective_date>Effective Date</t_effective_date> | |
<t_end_date>End Date</t_end_date> | |
<tertiary_current_deduct_p>Deductible Met (Current Year)</tertiary_current_deduct_p> | |
<tertiary_prior_deduct_p>Deductible Met (Prior Year)</tertiary_prior_deduct_p> | |
<tertiary_notes>Tertiary Insurance Notes</tertiary_notes> | |
<tertiary_primary>Primary</tertiary_primary> | |
<tertiary_medicare_contact>Medicare Contact</tertiary_medicare_contact> | |
<caller_type>Who is calling?</caller_type> | |
<caller_info>Info</caller_info> | |
<how_hear>How did you hear?</how_hear> | |
<how_hear_info>Info</how_hear_info> | |
<guarantor_type>Who pays the bills?</guarantor_type> | |
<guarantor_name>Name</guarantor_name> | |
<guarantor_phone_home>Home Phone</guarantor_phone_home> | |
<guarantor_phone_cell>Cell Phone</guarantor_phone_cell> | |
<guarantor_phone_work>Work Phone</guarantor_phone_work> | |
<guarantor_addr>Address</guarantor_addr> | |
<guarantor_city>City</guarantor_city> | |
<guarantor_state>State</guarantor_state> | |
<guarantor_zip>Zip</guarantor_zip> | |
<ec_name>Primary Contact Name</ec_name> | |
<ec_phone>Home Phone</ec_phone> | |
<ec_wphone>Work Phone</ec_wphone> | |
<ec_cphone>Cell Phone</ec_cphone> | |
<ec_relation>Relationship</ec_relation> | |
<ec_addr>Address</ec_addr> | |
<ec_city>City</ec_city> | |
<ec_state>State</ec_state> | |
<ec_zip>Zip</ec_zip> | |
<ec_other>Emergency Contact Notes</ec_other> | |
<ec2_name>Secondary Contact Name</ec2_name> | |
<ec2_phone>Home Phone</ec2_phone> | |
<ec2_wphone>Work Phone</ec2_wphone> | |
<ec2_cphone>Cell Phone</ec2_cphone> | |
<ec2_relation>Relationship</ec2_relation> | |
<ec2_addr>Address</ec2_addr> | |
<ec2_city>City</ec2_city> | |
<ec2_state>State</ec2_state> | |
<ec2_zip>Zip</ec2_zip> | |
<ec2_other>Emergency Contact Notes</ec2_other> | |
<pcp_name>PCP Name</pcp_name> | |
<pcp_phone>PCP Phone</pcp_phone> | |
<pcp_upin>PCP Upin #</pcp_upin> | |
<pcp_npi>PCP NPI #</pcp_npi> | |
<pcp_request>Request</pcp_request> | |
<cc_name>Cardholder's Name</cc_name> | |
<cc_other_auth>Person other than cardholder authorizing use</cc_other_auth> | |
<cc_today>Charge for today's services?</cc_today> | |
<cc_type>Card</cc_type> | |
<cc_number>Card # (16 digits)</cc_number> | |
<cc_sec_code>Auth Code</cc_sec_code> | |
<cc_exp>Expiration</cc_exp> | |
</legend> | |
</demographics> |
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