OMB#0935-0108
	PROVIDER ID:	W
	PROVIDER NAME:
	PATIENT ID:
	PATIENT NAME:
	MEDICAL  PROVIDER  COMPONENT
	PATIENT  DATA  FORM  FOR
	SEPARATELY BILLING DOCTORS
HOST HOSP/FACILITY NAME:
HOST HOSP/FACILITY ID:
A.	ADDITIONAL PROVIDER INFO:  See Section I
B.	OTHER NAMES FOR PATIENT AND SOC. SECURITY NUMBER:  See Authorization Form.
C.	PATIENT ADDRESS:
	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.	Dates of medical care below, supplied by the the hospital/facility where the patient received 
	treatment above, are of interest to this study.
	NODE ID	EVENT DATES	TYPE ( LOCATION ) OF EVENT
	( As reported by hospital/facilty, e.g. hospital ER, 
	( Reported by 	inpatient, or outpatient dept )
	.