Duke University School of Medicine - Aesculapian Yearbook (Durham, NC)

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The Doctor helps you to grow big stay well M

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PARTY SPONSOR C f C Q U Q Q . U O Q - l ' PRINTED s T E sv ND RD an svcn com' u s ,ZIPSETL DUKE PATIENT ROUTING FORM lj NEW PATIENT lj RETURN PATIENT UNIVERSITY I I MEDICAL CENTER OUTPATIENT DEPARTMENT CONTROL NO. DATE CHANGE IN PATIENT INFORMATION: ISPECIFYI CHIEF COMPLAINT CLINIC: III MEDICAL lj OB-GYN E PEDIATRICS E SURGERY EYE lj oRTHoPEDIcs - . INSURANCE DIC CODE TOTAL REGIS.CHRGS. OU AGENCY. D DPW D MDR U KSPECIW mow, E CC U VR AM NT CHARGED AMOUNT PAID E ' I CASH DTI-IER: E ISPECIFYJ , U CHECII CASE NAME: FIRST, Mm. INIT., LAST MONTH CLAIM No. PART DATE OF ELIGIBILITY sEx WELFARE , MEDICARE, EI A: I ' IDPWI X QMDRJ U B Mil 4 2 PAYMENT SOURCE FOR PATIENT: - CERTMCAT NO. GROUP E U E INSURANCE D NC BCIBS III CH- III D - E No' INFORMATION , OTHER: SELF PAY PUBLIC AGENCY INSURANCE U QDADQQQS FORM ffA-W5 REV- W' SPONSOHR PROGRAM OFFICE AND P-UTHORIZATION TO RELEASE .IlNru1w-'--'- OF BENEFITSY . tg ASSIGNMWT A auect , any to P y Y Dove named inSura'?EC?3ECTJCA:gMENT, BOX.38Olgu:'EE.C81 authorize the 8 TTER OUTPATIEN edical Servlce' e 1 hefebgvwsyyy MEDICAL GH Y fmay be due for m .bed on W insurfggim DUKE UN nefits whirl' . A service descfl MEDICAL C ' ' t af all be ' Oi-esslorml ' KE UNIVERSITY b Vemamed ig-Erica, Og ?n?3-,OERZIO ilciireby akiaioxage lifes entaE5gfNiZi,tXgiczsZarY PO 15 an gun . +I EZETDRTTEIIT DEPAR'5MI?g5'f iT,g-51-mation, medlcal or OI, . .. compfmf fm. and PYOCGSS W CML C I ' HIS AUTHORIZED AGENT . - PED OR 4' ' SIGNATURE OT WSU DAT E DAILY CASH REPOST DUKE HOSPITAL Osh ll 1l- Currency I 1,1l.i-ii ' Holves Quarters Dimes Nickels . .li1. . - 19 PeI'lI'lI65

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,,, ,X is. Lf . E ,- . It , fx W Pediatrics: First row L. to R: Seningen, Thaller, Osterhout, Brown, Hensen, Belmaker, Shanna, Smith, Katz, Hcmstreet, Kredich, Passero, Dees, Haskell, Manroe, Canent. Second row L. to R: Prince Wilfert, Buckley, Rogers, McBryde, Handwerger, Yancy, Sidbury, Kinsbourne. Third row L. to R: Hart, Topper, Tomeh, Freedberg, Martin, Brumley, Spock, Driscoll, Harris, Valiant, Raney, Porter. Fourth row L. to R: 0,Sl1C8, Miller, Lyon, Rixse, Pounds, McDaniel. Filth row L. to R: Love, Wood, Falterman, Baten, Wexler, WilkoH', Ottesen, Serwer, Benson, Spach, Grossman, Lusman, Lefkowitz. Sixth row L. to R: Anderson, Rogers, Widness. 21 fp