obsidian-yanxin/documents/medical/oral_surgery/201610181224191000.md

type, category, person, date, provider, source

type	category	person	date	provider	source
medical	oral surgery	Xuewei Jiang	2016-10-10	Midtown Oral & Maxillofacial Surgery	201610181224191000.jpg

Midtown Oral & Maxillofacial Surgery

H. Paul Casmedes, D.D.S., M.D. / Ann H Kristovich, D.D.S. Suite 410 Board Certified, American Board of Oral & Maxillofacial Surgery

901 West 38th Street, Austin, TX 78705

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Patient Type: New Patient

Pediatrician / Primary Care Doctor: Referring Physician: Dr. Mary Becher

Date: 10/10/2016

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PATIENT INFORMATION

Field	Value
Patient's Last Name	Jiang
First	Xuewei
Middle
Age	23
Sex	Female
Date of Birth	03/13/1993
Street Address	1652 W 6st Apt R
Social Security No.	092-99-3215
Primary Phone Number	(254) 214-1350
City	Austin
State	TX
ZIP Code	78703
Secondary Phone Number	(254) 224-1457

Ethnicity

• Hispanic or Latin
• Not Hispanic or Latin
• Refuse to Report

Race

• American Indian or Alaska Native
• Asian
• Native Hawaiian
• Black or African American
• White
• Hispanic
• Other Race
• Other Pacific Islander

Field	Value
Primary Parent / Guardian Name
Email
Social Security No.
Daytime Phone
Date of Birth
Employer
Employer phone No.
Second Parent / Guardian Name
Marital Status of Parents	Married

Emergency Contact

Field	Value
In case of emergency, please contact	Yanxin Lu
Phone Number	(254) 224-1457
Relation	Spouse

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INSURANCE INFORMATION

Primary Insurance

Field	Value
Type	Dental
Name of Primary Insurance	Delta Dental
Subscriber's Name	Xuewei Jiang
Subscriber's S.S. #	092-99-3215
Subscriber's Date of Birth	03/13/1993
Subscriber's Sex	Female
Policy No.	V17NK34D
Group No.	5968
Group Name
Subscriber Address
Patient's relationship to subscriber	Self
City	Austin
State	TX
ZIP Code	78703

Secondary Insurance

Field	Value
Name of Secondary Insurance	Blue Cross Blue Shield
Subscriber's Name	Xuewei Jiang
Subscriber's S.S. #	092-99-3215
Subscriber's Date of Birth	03/13/1993
Policy No.	V17NK34D
Group No.	071778
Group Name
Subscriber Address
Patient's relationship to subscriber	Self

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