Medical Administration Mod 3

Module 03 Course Project - Part 1

PATIENT REGISTRATION FORM

 Practice – The People’s Clinic

 Address – 1000 Town Square, Anytown Pennsylvania 54321

 Phone – 555-741-8529

PATIENT INFORMATION

 Patient – Mrs. Jane Doe

 Married

 Former name – Jane Smith

 DOB – 01/01/1960

 SSN - 123-45-6789

 Address – 123 Main Street, Anytown Pennsylvania 54321

 Phone – 555-987-6543

 Occupation – Nurse

 Employer – The People’s Hospital

 Employer Phone – 555-456-7890

 Doctor referral to clinic

INSURANCE INFORMATION

 Jane Doe is responsible for payment

 Primary insurance is Blue Cross Blue Shield

 Subscriber – Jane Doe

 ID – 123123123

 Grp – 00550055

 No secondary insurance

IN CASE OF EMERGENCY

 Suzie Smith (sister)

 Home – 555-567-8910

 Work – 555-678-9012

OUTPATIENT ENCOUNTER FORM

Jane Doe (chart #0987) saw Dr. Brown on 1-1-2015.

She is 5’5’’ tall and weighs 130 pounds

Her blood pressure was 120/70

Her pulse was 60

Her temperature was 98.6

This was her second visit with Dr. Brown after she was referred by Dr. White. She is seeing Dr. Brown

for adult onset IDDM (insulin dependent diabetes mellitus).

Jane’s visit was only for an office visit and laboratory tests. Dr. Brown spent 25 minutes with Jane at this

visit and ordered lab testing for Hemoglobin A1C. Jane needs to return to see Dr. Brown in 1 month.

When Jane checked out she gave the receptionist her encounter form which had the office visit at a cost

of $100. She paid the amount of her copayment which was $20.