Name: Peds Case, Patient Soc Sec No: 111-11-1111

Home address 111 Main Street, Fairfield, NJ 07004 Phone 973-555-5555.

Parent or guardian:

Father: Andrew,

Occupation: Architect, Smith Associates: Wayne, NJ, work phone: 973-444-4444

Insurance: United Healthcare; member 111-11-1111, group 222222

PCP: A. Gupta-973-666-6666

Family’s Medical History:

No congenital cardiac history.

This information could come from HIS-HL7 interface