PROVIDER ID :	WAVE :	OMB#0935-0108
PROVIDER  NAME :
PROVIDER ADDRESS :	(PREV RELEASE:	)
	,
	ID:
	NAME:
	PANEL:
	MEDICAL  PROVIDER  COMPONENT
	DATA  FORM
	A.	ADDITIONAL PROVIDER INFORMATION :
	OTHER NAMES FOR                       AND SOC.SECURITY NUMBER:	SEE AUTHORIZATION FORM
	B.	ADDRESS :
	C.	City , State , ZIP  :	,
	D.	DATE OF BIRTH  :	E.	SEX :
	F.	IF MARRIED ,
	Name of Spouse  :
	G.	IF INSURED
	Name of Policyholder(s)  :
	H.	IF 17 OR YOUNGER  :
	Parent Names  :
	a .	Father's Name  :
	b .	Mother's Name  :
	I.	The following information about medical care was supplied by the                 and is intended 
	ONLY as a guide for locating medical records and the records of charges and payments for all 
	care supplied to this                 between January 1, 2005 and December 31, 2005 .
	NUMBER OF EVENTS BY TYPE (LOCATION) OF EVENT  (as  reported  by      
	             e.g. office  visit, hospital ER, inpatient , or outpat. dept. )
	(ER)  :	(MV)
	(HS)  :	(HH) 
	(OP)  :	( IC)  :
	TOTAL  EVENTS :