Keith Clark
Sunrise Health  
ADMISSION FORM Printed: 2015 January 21 2:0  
patient  Unit #  Service/Location  Status  F/C  Date  Account#  
Keith Clark  BP876933  GENERAL SURGERY  DIS IN  HMOC  2015 January 21 BP47421474034  
PATIENT  PATIENT:EMPLOYER  
Soc Sec No:  D.O.B:  Age:  Sex:  MS:  Race:   
1997 November 09  28  F  M  B  BAP   
Address: 1334 Ramirez Light Apt. 991
Codymouth, MD 65269  
Home Phone: 425-173-1459   
County: HARRIS    
D.O.B: 1997 November 09    
Address: 1334 Ramirez Light Apt. 991
Codymouth, MD 65269
Phone: 425-173-1459   
D.O.B: 1997 November 09 
Rel To Patient: SPOUSE  
Comment:  INSURANCE # 1  Ins Policy # 876933   
Ins Verif: 2015 January 21  PO BOX 62217  
Rel to Pt: SELF  
D.O.B: 1997 November 09   
Eff. 10/06/22 to  Rel: Y Asgn: Y  Pre Cert 
Type  Accident:  11  ONSET OF SYMPTOMS/ILLNESS  2016 June 23  Type:
Preferred Land  EL  HMOC  ENG  PHYSICANS  Attending Physician:  
Dr Richard Meyer MD ADMISSION/REGISTRATION  Date:  Time: 
Source:  Rm/Bed:  Arrival:  Principal Admitting Diagnosis/Reason for Visit:
Admission Date:  2019 February 15  2:0  
CLINIC OR PHYSICIANS 0621/1  Stroke 
PQME6821  FACILITY COPY  Sunrise Health  Unit 9480 Box 3032
DPO AA 92757 
Marissa Alvarez  FACE  Acct# BP0001043784 MR # BP876933  FACESHEET  Page 60 of 99  
D.O.B: 1997 November 09  28 F 2024 March 03  EADMF0001 Rev. Date 09/2018  Dr Richard Meyer MD    
patient:Marissa Alvarez MRN:BP876933 Encounter:BP876933  Page 60 of  99