OB PreRegistration

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Advocate Illinois Masonic Medical Center.
OB Preregistration Information Summary
Due Date and Physician Information
Expected Due Date: August 20, 2014
Number of expected births: 1
Obstetrician: Rowland,Kathleen T., MD
Personal Information
First Name: LUZDIVINA
Middle Initial:
Last Name: VINE
Maiden or Alternate Name:
Social Security Number: 351-84-9296
Email Address
Email: LVINE1@GMAIL.COM
Street Address
Address Line 1: 6306 N KENMORE AVE
Address Line 2: APT 1
City: CHICAGO
State: Illinois
Zip Code: 60660
Phone: 630-809-1640
Demographics
Birth Date: December 17, 1984
Marital Status: Single
Primary Language: English
Place of Birth: New York
Ethnicity: Hispanic/Latino
Race: Multi-Racial
Religion: Catholic
Place Of Worship:
Employment Information
Employer: PRESENCE HEALTH
Address Line 1: 100 N RIVER ROAD
Address Line 2:
City: DES PLAINES
State: Illinois
Zip Code: 60016
Phone: 847-813-3955Ext.
Occupation: RESIDENT PHYSICIAN
Employment Status: Full Time
Baby(ies) Father's Employment Information
Employer: TEKLINK INTL INC
Address Line 1: 40 SHUMAN BLVD
Address Line 2:
City: NAPERVILLE
State: Illinois
Zip Code: 60563
Phone: 847-602-4055Ext.
Occupation: SOFTWARE ENGINEER
Employment Status: Full Time
Emergency Contact Information No. 1
First Name: DEEPAK
Middle Initial:
Last Name: NAGARAJAN
Address Line 1: 6166 N SHERIDAN RD
Address Line 2: APT 26D
City: CHICAGO
State: Illinois
Zip Code: 60660
Phone: 847-602-4055
Alternate Phone: --
Relationship to Patient: Friend
Emergency Contact Information No. 2
First Name: MARGARITA
Middle Initial:
Last Name: VINE
Address Line 1: 1203 WHISPERING HILLS CT
Address Line 2: APT 3B
City: NAPERVILLE
State: Illinois
Zip Code: 60540
Phone: 630-386-3629
Alternate Phone: --
Relationship to Patient: Mother
Primary Insurance Company - Policy Holder Information
First Name: LUZDIVINA
Middle Initial:
Last Name: VINE
Insurance Company Name: BCBS
Insurance Type: HMO
Policy/ID Number: XOH834948191
Group Number: H64593
Policy Holder Date of birth: December 17, 1984
Social Security Number: 351-84-9296
Relationship to Patient: Self
Policy Holder's Employer: PRESENCE HEALTH
Employer Address Line 1: 100 N RIVER ROAD
Employer Address Line 2:
Employer City: DES PLAINES
Employer State: Illinois
Employer Zip: 60016
Employer Phone Number: 847-813-3955
Claims Address Line 1:
Claims Address Line 2:
Claims City:
Claims State:
Claims Zip:
Customer Service Phone: 800-892-2803
Pre-Certification Phone: 800-676-2583
Pre-cert Number:
Secondary Insurance Company - Policy Holder Information
No Secondary Insurance Entered
Insurance Coverage for Baby(ies)
Primary Insurance: Mother
Secondary Insurance: Father
Other Insurance Company - Policy Holder Information
No Other Insurance Entered
Medicaid/Public Aid
Case Name:
Claims Address:
Case ID Number:
Recipient ID Number:
Eligibility Period:
Medicare
Medicare Name:
Medicare Number:
Disability Start Date:
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