Brian Martinez
Sunset Community Hospital  
ADMISSION FORM Printed: 16/07/2016 10:28  
Patient  Unit #  Service/Location  Status  F/C  Date  Account#  
Brian Martinez  BP369529  GENERAL SURGERY  DIS IN  HMOC  16/07/2016 BP16350413850  
PATIENT  PATIENT:EMPLOYER  
Soc Sec No:  DOB:  Age:  Sex:  MS:  Race:   
25/07/1987  28  F  M  B  BAP   
Address: 148 Burns Ferry
North Jeffreyfort, WA 48242  
Home Phone: 879-784-4713   
County: HARRIS    
DOB: 25/07/1987    
Address: 148 Burns Ferry
North Jeffreyfort, WA 48242
Phone: 879-784-4713   
DOB: 25/07/1987 
Rel To Patient: SPOUSE  
Comment:  INSURANCE # 1  Ins Policy # 369529   
Ins Verif: 16/07/2016  PO BOX 62747  
Rel to Pt: SELF  
DOB: 25/07/1987   
Eff. 10/06/22 to  Rel: Y Asgn: Y  Pre Cert 
Type  Accident:  11  ONSET OF SYMPTOMS/ILLNESS  15/11/2021  Type:
Preferred Land  EL  HMOC  ENG  PHYSICANS  Attending Physician:  
Dr Kelly Powell MD ADMISSION/REGISTRATION  Date:  Time: 
Source:  Rm/Bed:  Arrival:  Principal Admitting Diagnosis/Reason for Visit:
Date of Admit:  20/11/2016  10:28  
CLINIC OR PHYSICIANS 0674/1  Influenza 
PQME6821  FACILITY COPY  Sunset Community Hospital  3432 Miller Lights Suite 439
Port Aaron, KS 67881 
Robert Flores  FACE  Acct# BP0001043784 MR # BP369529  FACESHEET  Page 63 of 99  
DOB: 25/07/1987  28 F 25/03/2019  EADMF0001 Rev. Date 09/2018  Dr Kelly Powell MD    
Patient:Robert Flores MRN:BP369529 Encounter:BP369529  Page 63 of  99