Patient Referral/Admission Face Sheet

02/12/2004
Referral Date 12/01/2003 20:07:32 Admission Date Code Status Patient Name DOB Marital Status Address County Home Phone Facility Name Room No Emergency Home Phone Diagnosis Level Of Care Medicare No Geramy, Ron 04/30/1959 Divorced SSN Age 345-87-0965 44 Name Of Spouse Medical Record No Gender 12/01/2003 DNR 345212 Male

43 32nd St, Apt 224, New York, New York 23349 Hevershire 499-303-3933 Golden Rule 546 Randy Geramy 404-444-3033 Work Phone 344-490-3494 MSA Code Race Type Bed No Caucasian Long Term Care 34 Relationship Mobile Phone ICD9 Code Brother 344-344-9393 200.26 Religion Phone Catholic 765-966-7681

burkitt's tumor or lymphoma involv intrapelvic lymph nodes

652-Continuous Care 15 45432 Medicaid No Gender Relationship 2455 Male Brother Insurance No Age 45632 45

Primary Care Giver Name Address Home Phone Randy Geramy

7088 West 9th Sty, New York, New York 89339 404-444-3033 Work Phone MCD Provider No 344-490-3494 34562346 Mobile Phone UPIN No 344-344-9393 235314643

Attending Physician Physician Name Dr. Bahrami, Mohammed Address Office Phone 2nd Physician Address Office Phone DME Provider DME Orders Grandview

1420 Pilgrim Blvd, Yorktown, IN 47396 765-788-1234 Second Phone MCD Provider Fax UPIN No 765-888-1234

Second Phone Phone 765-827-0847

Fax Fax 765-827-5555

Wheelchair, Hospital Bed, Full Side Rails

Pharmacy

Neighbor Care

Phone

877-440-5544

Fax

877-839-1911 Chase, Bradley Gould, Peggie

Hospice Assignments Nurse Aid Funeral Home Driving Directions Referral Source Ken Irwin Referral Taken Irwin, Ken

Hospice Office Covenant Hospice RN Chaplain Phone Davis, Craig Social Worker Address

Title

Adminstrator

Phone

858-555-1212