ANGELA DILALIO MD 99 PROVIDER DRIVE INJURY NY 12347 101 201 4321 Patient Number: 1-16 EIN: 111982342 NPI: 4567890123 PATIENT INFORMATION: INSURANCE INFORMATION: Name: LEWIS, TERRY Primary Insurance Address: 9 RANDOLPH ROAD Primary Insurance Name: TRICARE City: ANYWHERE Address: PO BOX 555 State: NY City: TRICITY Zip/4: 12345-1234 State: SC Telephone: 101 5555169 Zip/4: 76654-0555 Gender: M x F Plan IDA: 562356989 Status: Single x Married Other Group #: Date of Birth: 05 05 1986 Primary Policyholder. LEWIS, TERRY Employer: US NAVY Address: 9 RANDOLPH ROAD Student: FT PT School: City: ANYWHERE State: NY Work Related? Y NX Zip/4: 12345-1234 Auto Accident? N X State Policyholder Date of Birth: Other Accident: v Pt Relationship to Insured: Self x Spouse Child Other Date of Accident: Employer/School Name: US NAVY Secondary Insurance Referring Physician: Secondary Insurance Name: Address Address: Telephone: City: NPI #: State: Zip/4: Plan ID4: Group #: Primary Policyholder. Address: City: State: Zip/4: Policyholder Date of Birth: Pt Relationship to Insured: Self Spouse Child Other Employer School Name: ENCOUNTER INFORMATION: Place of Service: 11 DIAGNOSIS INFORMATION Code Diagnosis Code Diagnosis