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<demographics>
<id>demo.2010-01-14.6557744442</id>
<title>Demographics</title>
<subject>
</subject>
<description>
</description>
<contributors>
</contributors>
<creators>
</creators>
<effectivedate>
</effectivedate>
<expirationdate>
</expirationdate>
<language>
</language>
<rights>
</rights>
<creation_date>2010/01/14 16:50:56.006 US/Pacific</creation_date>
<modification_date>2010/05/11 16:33:32.270 GMT-7</modification_date>
<intake>2010/01/14</intake>
<last>Test</last>
<first>User</first>
<middle>
</middle>
<nickname>
</nickname>
<address>
</address>
<city>
</city>
<county>
</county>
<state>
</state>
<zip>
</zip>
<lat_long>
</lat_long>
<mail_to>
</mail_to>
<mail_address>
</mail_address>
<mail_city>
</mail_city>
<mail_state>
</mail_state>
<mail_zip>
</mail_zip>
<phone_number>
</phone_number>
<alt_phone_number>
</alt_phone_number>
<ssn>
</ssn>
<dob>
</dob>
<sex>
</sex>
<alone>
</alone>
<cross_street>
</cross_street>
<facility_name>
</facility_name>
<caller>
</caller>
<caller_num>
</caller_num>
<caller_relation>
</caller_relation>
<loc_type>Home</loc_type>
<janus_id>DEMO_1195</janus_id>
<alternate_id>
</alternate_id>
<alerts>
</alerts>
<otheralert>
</otheralert>
<patient_status>Current</patient_status>
<reason_for_discharge>
</reason_for_discharge>
<date_of_death>
</date_of_death>
<directives>
</directives>
<allergies>
</allergies>
<noknownallergies>
</noknownallergies>
<disposition>
</disposition>
<pharmacy>
</pharmacy>
<pharmacy_num>
</pharmacy_num>
<pharmacy_fax>
</pharmacy_fax>
<home_health>
</home_health>
<home_health_contact>
</home_health_contact>
<home_health_num>
</home_health_num>
<home_health_fax>
</home_health_fax>
<map_page>
</map_page>
<clinician_name>demo1</clinician_name>
<last_checkup>
</last_checkup>
<last_hospitalization>
</last_hospitalization>
<known_diagnoses>
</known_diagnoses>
<other_known_diagnoses>
</other_known_diagnoses>
<midlevel_name>
</midlevel_name>
<chief_complaint>
</chief_complaint>
<treatment_days>
</treatment_days>
<treatment_type>
</treatment_type>
<dispatchers_notes>
</dispatchers_notes>
<primary_type>Commercial</primary_type>
<primary_carrier_code>
</primary_carrier_code>
<primary_carrier>dsfdfsd</primary_carrier>
<primary_policy_holder_relationship>1</primary_policy_holder_relationship>
<primary_policy_holder_name>
</primary_policy_holder_name>
<primary_certificate_num>sfsdfsdf</primary_certificate_num>
<primary_group_num>
</primary_group_num>
<primary_addr1>
</primary_addr1>
<primary_city>
</primary_city>
<primary_st>
</primary_st>
<primary_zip>
</primary_zip>
<primary_phone>
</primary_phone>
<p_part_b_verified>
</p_part_b_verified>
<p_effective_date>
</p_effective_date>
<p_end_date>
</p_end_date>
<primary_current_deduct_p>
</primary_current_deduct_p>
<primary_prior_deduct_p>
</primary_prior_deduct_p>
<primary_notes>
</primary_notes>
<primary_primary>
</primary_primary>
<primary_medicare_contact>
</primary_medicare_contact>
<secondary_type>
</secondary_type>
<secondary_carrier_code>
</secondary_carrier_code>
<secondary_carrier>
</secondary_carrier>
<secondary_policy_holder_relationship>1</secondary_policy_holder_relationship>
<secondary_policy_holder_name>
</secondary_policy_holder_name>
<secondary_certificate_num>
</secondary_certificate_num>
<secondary_group_num>
</secondary_group_num>
<secondary_addr1>
</secondary_addr1>
<secondary_city>
</secondary_city>
<secondary_st>
</secondary_st>
<secondary_zip>
</secondary_zip>
<secondary_phone>
</secondary_phone>
<s_part_b_verified>
</s_part_b_verified>
<s_effective_date>
</s_effective_date>
<s_end_date>
</s_end_date>
<secondary_current_deduct_p>
</secondary_current_deduct_p>
<secondary_prior_deduct_p>
</secondary_prior_deduct_p>
<secondary_notes>
</secondary_notes>
<secondary_primary>
</secondary_primary>
<secondary_medicare_contact>
</secondary_medicare_contact>
<tertiary_type>
</tertiary_type>
<tertiary_carrier_code>
</tertiary_carrier_code>
<tertiary_carrier>
</tertiary_carrier>
<tertiary_policy_holder_relationship>1</tertiary_policy_holder_relationship>
<tertiary_policy_holder_name>
</tertiary_policy_holder_name>
<tertiary_certificate_num>
</tertiary_certificate_num>
<tertiary_group_num>
</tertiary_group_num>
<tertiary_addr1>
</tertiary_addr1>
<tertiary_city>
</tertiary_city>
<tertiary_st>
</tertiary_st>
<tertiary_zip>
</tertiary_zip>
<tertiary_phone>
</tertiary_phone>
<t_part_b_verified>
</t_part_b_verified>
<t_effective_date>
</t_effective_date>
<t_end_date>
</t_end_date>
<tertiary_current_deduct_p>
</tertiary_current_deduct_p>
<tertiary_prior_deduct_p>
</tertiary_prior_deduct_p>
<tertiary_notes>
</tertiary_notes>
<tertiary_primary>
</tertiary_primary>
<tertiary_medicare_contact>
</tertiary_medicare_contact>
<caller_type>
</caller_type>
<caller_info>
</caller_info>
<how_hear>
</how_hear>
<how_hear_info>
</how_hear_info>
<guarantor_type>
</guarantor_type>
<guarantor_name>
</guarantor_name>
<guarantor_phone_home>
</guarantor_phone_home>
<guarantor_phone_cell>
</guarantor_phone_cell>
<guarantor_phone_work>
</guarantor_phone_work>
<guarantor_addr>
</guarantor_addr>
<guarantor_city>
</guarantor_city>
<guarantor_state>
</guarantor_state>
<guarantor_zip>
</guarantor_zip>
<ec_name>
</ec_name>
<ec_phone>
</ec_phone>
<ec_wphone>
</ec_wphone>
<ec_cphone>
</ec_cphone>
<ec_relation>
</ec_relation>
<ec_addr>
</ec_addr>
<ec_city>
</ec_city>
<ec_state>
</ec_state>
<ec_zip>
</ec_zip>
<ec_other>
</ec_other>
<ec2_name>
</ec2_name>
<ec2_phone>
</ec2_phone>
<ec2_wphone>
</ec2_wphone>
<ec2_cphone>
</ec2_cphone>
<ec2_relation>
</ec2_relation>
<ec2_addr>
</ec2_addr>
<ec2_city>
</ec2_city>
<ec2_state>
</ec2_state>
<ec2_zip>
</ec2_zip>
<ec2_other>
</ec2_other>
<pcp_name>
</pcp_name>
<pcp_phone>
</pcp_phone>
<pcp_upin>
</pcp_upin>
<pcp_npi>
</pcp_npi>
<pcp_request>
</pcp_request>
<cc_name>
</cc_name>
<cc_other_auth>
</cc_other_auth>
<cc_today>
</cc_today>
<cc_type>
</cc_type>
<cc_number>
</cc_number>
<cc_sec_code>
</cc_sec_code>
<cc_exp>
</cc_exp>
<legend>
<id>Short Name</id>
<title>Title</title>
<subject>Keywords</subject>
<description>Description</description>
<contributors>Contributors</contributors>
<creators>Creators</creators>
<effectiveDate>Effective Date</effectiveDate>
<expirationDate>Expiration Date</expirationDate>
<language>Language</language>
<rights>Copyrights</rights>
<creation_date>Creation Date</creation_date>
<modification_date>Modification Date</modification_date>
<intake>Intake Date</intake>
<last>Last Name</last>
<first>First Name</first>
<middle>Middle Name</middle>
<nickname>Nick Name</nickname>
<address>Street Address</address>
<city>City</city>
<county>County</county>
<state>State</state>
<zip>Zip</zip>
<lat_long>Lat_long</lat_long>
<mail_to>Address Mail to</mail_to>
<mail_address>Mailing Street Address</mail_address>
<mail_city>Mailing City</mail_city>
<mail_state>Mailing State</mail_state>
<mail_zip>Mailing Zip</mail_zip>
<phone_number>Phone</phone_number>
<alt_phone_number>Alternate Phone</alt_phone_number>
<SSN>SSN</SSN>
<DOB>Date of birth</DOB>
<Sex>Sex</Sex>
<alone>Patient lives alone?</alone>
<cross_street>Cross Street</cross_street>
<facility_name>Facility Name</facility_name>
<caller>Caller - Referral Source</caller>
<caller_num>Caller's Phone #</caller_num>
<caller_relation>Relationship to Patient</caller_relation>
<loc_type>Location Type</loc_type>
<janus_id>Janus ID</janus_id>
<alternate_id>Alternate Patient ID</alternate_id>
<alerts>Alerts</alerts>
<otherAlert>Other Alert</otherAlert>
<patient_status>Patient Status</patient_status>
<reason_for_discharge>Reason for Discharge</reason_for_discharge>
<date_of_death>Date of Death</date_of_death>
<directives>Consents and Advanced Directives</directives>
<allergies>Please describe any allergies and adverse reactions</allergies>
<noKnownAllergies>No known drug allergies</noKnownAllergies>
<disposition>Disposition</disposition>
<pharmacy>Pharmacy</pharmacy>
<pharmacy_num>Pharmacy Phone</pharmacy_num>
<pharmacy_fax>Pharmacy Fax</pharmacy_fax>
<home_health>Home Health Agency</home_health>
<home_health_contact>Home Health Contact</home_health_contact>
<home_health_num>Home Health Phone</home_health_num>
<home_health_fax>Home Health Fax</home_health_fax>
<map_page>Map page</map_page>
<clinician_name>Physician Name</clinician_name>
<last_checkup>Last Physician Checkup</last_checkup>
<last_hospitalization>Last Hospitalization</last_hospitalization>
<known_diagnoses>Known Diagnoses</known_diagnoses>
<other_known_diagnoses>Other Known Diagnoses</other_known_diagnoses>
<midlevel_name>Non-Physician Practitioner Name</midlevel_name>
<chief_complaint>Initial Complaint</chief_complaint>
<treatment_days>Treatment Days</treatment_days>
<treatment_type>Type of Treatment</treatment_type>
<dispatchers_notes>Dispatcher Notes</dispatchers_notes>
<primary_type>Primary Coverage Type</primary_type>
<primary_carrier_code>Primary Insurance Carrier</primary_carrier_code>
<primary_carrier>Carrier Name</primary_carrier>
<primary_policy_holder_relationship>Policy Holder</primary_policy_holder_relationship>
<primary_policy_holder_name>Policy Holder Name</primary_policy_holder_name>
<primary_certificate_num>Certificate #</primary_certificate_num>
<primary_group_num>Group #</primary_group_num>
<primary_addr1>Mailing Address</primary_addr1>
<primary_city>City</primary_city>
<primary_st>State</primary_st>
<primary_zip>Zip</primary_zip>
<primary_phone>Phone Number</primary_phone>
<p_part_b_verified>Verification</p_part_b_verified>
<p_effective_date>Effective Date</p_effective_date>
<p_end_date>End Date</p_end_date>
<primary_current_deduct_p>Deductible Met (Current Year)</primary_current_deduct_p>
<primary_prior_deduct_p>Deductible Met (Prior Year)</primary_prior_deduct_p>
<primary_notes>Primary Insurance Notes</primary_notes>
<primary_primary>Primary</primary_primary>
<primary_medicare_contact>Medicare Contact</primary_medicare_contact>
<secondary_type>Coverage Type</secondary_type>
<secondary_carrier_code>Insurance Carrier</secondary_carrier_code>
<secondary_carrier>Carrier Name</secondary_carrier>
<secondary_policy_holder_relationship>Policy Holder</secondary_policy_holder_relationship>
<secondary_policy_holder_name>Policy Holder Name</secondary_policy_holder_name>
<secondary_certificate_num>Certificate #</secondary_certificate_num>
<secondary_group_num>Group #</secondary_group_num>
<secondary_addr1>Mailing Address</secondary_addr1>
<secondary_city>City</secondary_city>
<secondary_st>State</secondary_st>
<secondary_zip>Zip</secondary_zip>
<secondary_phone>Phone Number</secondary_phone>
<s_part_b_verified>Verification</s_part_b_verified>
<s_effective_date>Effective Date</s_effective_date>
<s_end_date>End Date</s_end_date>
<secondary_current_deduct_p>Deductible Met (Current Year)</secondary_current_deduct_p>
<secondary_prior_deduct_p>Deductible Met (Prior Year)</secondary_prior_deduct_p>
<secondary_notes>Secondary Insurance Notes</secondary_notes>
<secondary_primary>Primary</secondary_primary>
<secondary_medicare_contact>Medicare Contact</secondary_medicare_contact>
<tertiary_type>Coverage Type</tertiary_type>
<tertiary_carrier_code>Insurance Carrier</tertiary_carrier_code>
<tertiary_carrier>Carrier Name</tertiary_carrier>
<tertiary_policy_holder_relationship>Policy Holder</tertiary_policy_holder_relationship>
<tertiary_policy_holder_name>Policy Holder Name</tertiary_policy_holder_name>
<tertiary_certificate_num>Certificate #</tertiary_certificate_num>
<tertiary_group_num>Group #</tertiary_group_num>
<tertiary_addr1>Mailing Address</tertiary_addr1>
<tertiary_city>City</tertiary_city>
<tertiary_st>State</tertiary_st>
<tertiary_zip>Zip</tertiary_zip>
<tertiary_phone>Phone Number</tertiary_phone>
<t_part_b_verified>Verification</t_part_b_verified>
<t_effective_date>Effective Date</t_effective_date>
<t_end_date>End Date</t_end_date>
<tertiary_current_deduct_p>Deductible Met (Current Year)</tertiary_current_deduct_p>
<tertiary_prior_deduct_p>Deductible Met (Prior Year)</tertiary_prior_deduct_p>
<tertiary_notes>Tertiary Insurance Notes</tertiary_notes>
<tertiary_primary>Primary</tertiary_primary>
<tertiary_medicare_contact>Medicare Contact</tertiary_medicare_contact>
<caller_type>Who is calling?</caller_type>
<caller_info>Info</caller_info>
<how_hear>How did you hear?</how_hear>
<how_hear_info>Info</how_hear_info>
<guarantor_type>Who pays the bills?</guarantor_type>
<guarantor_name>Name</guarantor_name>
<guarantor_phone_home>Home Phone</guarantor_phone_home>
<guarantor_phone_cell>Cell Phone</guarantor_phone_cell>
<guarantor_phone_work>Work Phone</guarantor_phone_work>
<guarantor_addr>Address</guarantor_addr>
<guarantor_city>City</guarantor_city>
<guarantor_state>State</guarantor_state>
<guarantor_zip>Zip</guarantor_zip>
<ec_name>Primary Contact Name</ec_name>
<ec_phone>Home Phone</ec_phone>
<ec_wphone>Work Phone</ec_wphone>
<ec_cphone>Cell Phone</ec_cphone>
<ec_relation>Relationship</ec_relation>
<ec_addr>Address</ec_addr>
<ec_city>City</ec_city>
<ec_state>State</ec_state>
<ec_zip>Zip</ec_zip>
<ec_other>Emergency Contact Notes</ec_other>
<ec2_name>Secondary Contact Name</ec2_name>
<ec2_phone>Home Phone</ec2_phone>
<ec2_wphone>Work Phone</ec2_wphone>
<ec2_cphone>Cell Phone</ec2_cphone>
<ec2_relation>Relationship</ec2_relation>
<ec2_addr>Address</ec2_addr>
<ec2_city>City</ec2_city>
<ec2_state>State</ec2_state>
<ec2_zip>Zip</ec2_zip>
<ec2_other>Emergency Contact Notes</ec2_other>
<pcp_name>PCP Name</pcp_name>
<pcp_phone>PCP Phone</pcp_phone>
<pcp_upin>PCP Upin #</pcp_upin>
<pcp_npi>PCP NPI #</pcp_npi>
<pcp_request>Request</pcp_request>
<cc_name>Cardholder's Name</cc_name>
<cc_other_auth>Person other than cardholder authorizing use</cc_other_auth>
<cc_today>Charge for today's services?</cc_today>
<cc_type>Card</cc_type>
<cc_number>Card # (16 digits)</cc_number>
<cc_sec_code>Auth Code</cc_sec_code>
<cc_exp>Expiration</cc_exp>
</legend>
</demographics>
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