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Patient Information
Submitted HIC #:	XXXXXXXXXA
Active HIC #:	XXXXXXXXXA
First Name:	Jane
Middle Initial:	B
Last Name:	Smith
Gender:	Female
Address 1:	6971 N Federal Hwy.
Address 2:	Suite 300
City, State Zip code:	Boca Raton, FL 33487
Date of Birth:	01/21/1920
Date of Death:

Medicare Eligibility
Eligibility Status:	Active Coverage
Medicare Type:	Medicare Part A
Date of Entitlement:	12/01/2008
Date of Termination:

Medicare Eligibility
Eligibility Status:	Active Coverage
Medicare Type:	Medicare Part B
Date of Entitlement:	12/01/2008
Date of Termination:

PPS
NPI #:	XXXXXXXXXX
Start Date:	10/18/2009
End Date:	12/16/2009
DOEBA:
DOLBA:
Intermediary Name:	Palmetto GBA
Intermediary #:	00380

PPS
NPI #:	XXXXXXXXXX
Start Date:	01/14/2009
End Date:	03/14/2009
DOEBA:	01/14/2009
DOLBA:	03/11/2009
Intermediary Name:	Palmetto GBA
Intermediary #:	00380

MSP
Effective Date:	11/08/2009
Termination Date:
Insurer Name:	The Insurer Name
Policy #:	XXXXXXXXX
Address:	600 North 10th Street
City, State Zip code	Miami, FL 33122

HMO
Enrollment Date:	09/01/2009
Termination Date:
HMO Name:	The HMO Name
Plan Id / Plan Type:	HXXXX 068
Option Code:	C
Address:	115 Main Blvd
Address 2:
City, State Zip code:	Tampa, FL 33614
Phone #:	(800) 000-0000

Hospice
Start Date:	09/15/2007
End Date:
NPI # / Provider #:	XXXXXXXXXX
Revocation Indicator:	1

Hospital/SNF
Lifetime Reserve:	60
Inpatient Deductible:	0.00
Full Hospital Days Remaining:	59
Co-Hospital Days Remaining:	30
Full SNF Days Remaining:	20
Co-SNF Days Remaining:	80
DOEBA:	11/11/2009
DOLBA:	11/12/2009

Run Date: 1/22/2010 09:03:55 AM - © 2009 Episode Alert

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