ocr: Personal intormation Insurance Information Last Name:Smith First Name:Terry Ins. ID: Hadress:1219 James Street Special Handling Hddress:Hpt. 347 City/State:0 Lincoln, NE -Reason For Treatment Zip Code: 68509-0347 Phone: (402)486-4837 Sex:M uccupational Ilness/Injury Birth Date:12/15/4b Age42 Accident Rel. To Guarantor:1 Patient Is Insured Auto ) - Other Rel. To Spouse:2 Spouse Referrals By :R1 Look-Up Name:Susan Green Date: 12/19/87 Thank 1 By Look-Up Name: Date: Thank By Look-Up Name: Date: Thank By Look-Up Name: Date: Thank
