Christopher Stevenson
Southwest Medical  
ADMISSION FORM Printed: 2014 September 06 5:15  
Patient name  Unit #  Service/Location  Status  F/C  Date  Account#  
Christopher Stevenson  BP689563  GENERAL SURGERY  DIS IN  HMOC  2014 September 06 BP87753002425  
PATIENT  PATIENT:EMPLOYER  
Soc Sec No:  dob:  Age:  Sex:  MS:  Race:   
2000 August 21  34  F  M  B  BAP   
Address: 8251 Danielle Squares
New Brittanyhaven, IL 94905  
Home Phone: 861-258-5382   
County: HARRIS    
dob: 2000 August 21    
Address: 8251 Danielle Squares
New Brittanyhaven, IL 94905
Phone: 861-258-5382   
dob: 2000 August 21 
Rel To Patient: SPOUSE  
Comment:  INSURANCE # 1  Ins Policy # 689563   
Ins Verif: 2014 September 06  PO BOX 62517  
Rel to Pt: SELF  
dob: 2000 August 21   
Eff. 10/06/22 to  Rel: Y Asgn: Y  Pre Cert 
Type  Accident:  11  ONSET OF SYMPTOMS/ILLNESS  2014 December 09  Type:
Preferred Land  EL  HMOC  ENG  PHYSICANS  Attending Physician:  
Dr Christine Walker MD ADMISSION/REGISTRATION  Date:  Time: 
Source:  Rm/Bed:  Arrival:  Principal Admitting Diagnosis/Reason for Visit:
Date of Admit:  2023 October 26  5:15  
CLINIC OR PHYSICIANS 0651/1  Anemia 
PQME6821  FACILITY COPY  Southwest Medical  171 White Burgs
Brittanyborough, WI 61326 
Sally Powers  FACE  Acct# BP0001043784 MR # BP689563  FACESHEET  Page 48 of 99  
dob: 2000 August 21  34 F 2023 June 25  EADMF0001 Rev. Date 09/2018  Dr Christine Walker MD    
Patient name:Sally Powers MRN:BP689563 Encounter:BP689563  Page 48 of  99