Mrs. Cynthia Guerra
Sunrise Health  
ADMISSION FORM Printed: 2017-07-18 2:6  
PATIENT  Unit #  Service/Location  Status  F/C  Date  Account#  
Mrs. Cynthia Guerra  BP414188  GENERAL SURGERY  DIS IN  HMOC  2017-07-18 BP48652563629  
PATIENT  PATIENT:EMPLOYER  
Soc Sec No:  date of birth:  Age:  Sex:  MS:  Race:   
2000-02-23  72  F  M  B  BAP   
Address: 74893 Steven Parkway
Danielton, HI 40334  
Home Phone: 742-135-1273   
County: HARRIS    
date of birth: 2000-02-23    
Address: 74893 Steven Parkway
Danielton, HI 40334
Phone: 742-135-1273   
date of birth: 2000-02-23 
Rel To Patient: SPOUSE  
Comment:  INSURANCE # 1  Ins Policy # 414188   
Ins Verif: 2017-07-18  PO BOX 62387  
Rel to Pt: SELF  
date of birth: 2000-02-23   
Eff. 10/06/22 to  Rel: Y Asgn: Y  Pre Cert 
Type  Accident:  11  ONSET OF SYMPTOMS/ILLNESS  2023-09-11  Type:
Preferred Land  EL  HMOC  ENG  PHYSICANS  Attending Physician:  
Dr Patrick English MD ADMISSION/REGISTRATION  Date:  Time: 
Source:  Rm/Bed:  Arrival:  Principal Admitting Diagnosis/Reason for Visit:
admission date:  2019-03-20  2:6  
CLINIC OR PHYSICIANS 0638/1  Myocardial Infarction 
PQME6821  FACILITY COPY  Sunrise Health  73397 Cody Street
South Matthew, FM 40249 
Robert Shepherd  FACE  Acct# BP0001043784 MR # BP414188  FACESHEET  Page 71 of 99  
date of birth: 2000-02-23  72 F 2020-08-07  EADMF0001 Rev. Date 09/2018  Dr Patrick English MD    
PATIENT:Robert Shepherd MRN:BP414188 Encounter:BP414188  Page 71 of  99