Document V3b5vRX4oKVR6VaDmnGp8JrMj
GROUP HOSPITAL INSURANCE REPORT
Coverage To. Confirmed by.
Date _
Attention.
Clerk.
2. Name of Insurance Company.
JOHN HANCOCK INSURANCE CO.
^3. Name of Group
AMERICAN CYANIDE CO. (THRU MAC GREGOR LEAD CO.)
Address *^00 WEST 1HTH STREET CHICAGO, ILLINOIS 6o623
4. Name of Person Insured MR. CALVIN DAVIS AXW. 6r 7 NORTH LAWNDALE
CHICAGO, ILLINOIS 60624
5. Name of
MAVDENE DAVID (MRS. CALVIN)
Relationship to Person Insured 6. Admitted to Hospital ---7. Discharged^__________________
WIFE
11-18-71
< DATs)
It-JD -1!
.Age.
26
At. At.
8. Diagnosis from Records:
Operations or Obstetrical Procedures Performed: Nature^ Date
9. Type of accommodation: Private
ATTACH COPY OF ITEMIZED 8ILL
CONFIDENTIAL in f o r ma t io n
r edac t ed
Semi-private
.Ward
Hospital. HOSPITAL/ PASSAVANT MEMORIAL 303 EAST SUPER I OR "STREET
Address _ CHICAGO, ILLINOIS
Taken from~*eeofds on
/(
/OAT)
60611
Signed ba
* A-Si ,fy^_~nQxx
title____ fty^AAxJh.y---------1--
10. AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize the aboove-nameda hnosptiitaal to release the infor
mation requested on this form.
11-88=71
Date.
.X .Signature
S SIGNATURE - (PARENT 0 GUARDIAN IF FATIENT IS 4 NINON*
II. ASSIGNMENT OF INSURANCE BENERTS: l hereby authorize payment directly to the above-named hospital of the hospital expense benefits otherwise payable to me, but not to exceed the hospital's regular charges for this period of hospitalization. I understand that I am fimnaannccially responsible to the hospital ftor the charges not covered by my
Group Insurance Plan.
Date.
11-18-71
. Signature
(SIGNATURE OF PERSON INSUMO)
ThU form prepared and di$tributed by the Chicago Hoipital Council
KEVISEO APHIS. I. !
INSURANCE COPY
CYWI 4-001380
DETAIL OF
SERVICES RENDERED
INSURANCE *1 COPY
PASSAVANT MEMORIAL HOSPITAL
303 CAST SUPERIOR STREET. CHICAGO. ILLINOIS 60611
Northweetern Univ*r,ty - McCow Medical Center
41
PATIENT
r
MTAOIL MR
L.
f 1ST INSUBANC* COMP ANY 2ND INSURANCE COMPANY DATE MO. 1 RAY 1 YB.
sex( PATIENT NO.
AGE
MRS OAVT S r MAYDENF
-
PAVIS CALVIN 637 N LAWNDALE
CHICAGO
IL
JOHN HANCOCK
^
60624
45593 F 26
TO INSURE PROPER CREOIT TO YOUR ACCOUNT; PlEASE 0TACH ANO RETURN THIS PORTION WITH YOUR REMITTANCE.
J rtM M.OMS t his rcnroe*TioN (
GROUP
REG. ITEM cooc
CHARGE DESCRIPTION
TOTAL CHARGE OR CREOIT
ADMITTED
DISCHARGED
P--____________________i
CURRENT
,
11/18/71 11/20/71 11/23/71;
POLICY NUMBER
EST1MATEO IN S. COVERAGE
1ST
2ND
PLAN NO.
310
PAYABLE BY PATIENT
RM b o a r d AN6T 0/R X-RAY LAB MED SUPP PHARH BLOOD OTHER p a t Hfstf j--; CASH, . Jgf*'
110.00 00 00
2.46 .0*
8.20 .00 $
15*00 .60 6Qp '
-
v-L; ;
,,. -,w4- ~v
-
In f o r ma t io n REDACTED
PATIENT V.
AoomoNAi w il in g wia ie s e n t t o y o u f o c h a r g e s n o t WCOROED AT THE TIME OP YOUR DISCHARGE.
RAT1CNT NO.
135.60
TOTAL CHARGE OR CREDIT
135.66
1ST.
2ND.
ESTIMATED INS. COVERAGE
NOTE; MINUS SIGN t-J tNOtCATCS CREOIT.
FASSAVAMT MIMOtIM HOSFtTAL CHICAGO, ILLINOIS
.00
PAYABLE BY PATIENT
CYWI 4-001381
OCTAIL Of
SCIVtCtS tENDCftEO
INSURANCE -1 COPY
PASSAVANT `MEMORIAL HOSPITAL
303 CAST SUPERIOR STRUT. CHICAGO. ILLINOIS 6041 I
NoiHliw.tl.rn Univ*rity - M<Gow Alditol Cantor
41
( PATIENT NO. sex
AGE
.OMITTED
DISCHARGED
CURRENT
|
PATIENT
MRS. DAVlSt MAYDENE
45593 F 26 11/10/71 11/20/71 11/23/71^
MAIL TO
MR DAVIS* CALVIN 637 H IAWNOALE
CHICAGO
o
It 60624
TO INSURE PROPER CREDIT TO root ACCOUNT. PHASE 0*. TACH ANO RETURN THIS
PORTION WITH TOUR REMIT TANCE
AMOUNT Of REMITTANCE. IOCIAJ. SECURITY NO.
JOHN HANCOCK
1NO
NIUtMCt COMPAMT
OAT* NO. I DAT I VW.
KG. rrtM COM
J rtMt m r-- y>m roroAro#
6 A 00*
POLICY NUWVO
CHARGE OCSOdmOM
TOoTrALoCtcHoArRrGE
ESTIMATED MS. COVERAGE
nNA^ct MCO*ej*c
310
PAYARLE 6Y PATIENT
11/18/71 1 11/19/71 1
r 11/20/71 54 1 St/22/71 61 99
U/20/71 80 44 11/23/71 19 I 11/20/71 91 3
ROOM C BOARD RM 802*1 ROOM C BOARD RM 802*1 EMERGENCY ROOM MCO-SORG AOM SETS
TECEMHONE ROUTINE URINALYSIS *a y t **a t ie n t
55.00 55.00 15*00
8*20
60 2.46
v 69-
*V t .
:
\i\u;, ll = *44' * {,
V-
f.
fc 'J,i tf
*
c o NmI?io n
PATIENT
MRS* OAVIS* MAYOENE
AD0iTiO-*Al 8ILIINC Win SE SENT TO TOU eOR CHARGES NO' RECOROtO AT THE TImE OF TOUR OISCHARGC.
45593
PATIENT NO.
135*66
t o t al c hang e OR CREOIT
1ST.
2ND.
ESTIMATED INS. COVERAGE
NOTE: MINUS SIGN (-) INDICATES CREDIT
PAYASLE *Y PATIENT
PAttAVAMT MIMOCIAL HOSPITAL CHICAGO, ILLINOIS
CYW1 4-00X382