Precision Surgicenter Patient Summary Information

with proc w sig

39180 FARWELL DRIVE (510) 494-0800
Fremont, CA 94538

Patient: Watts, Dennis Sex: Male Account: 3009

Address: 2405 Olea Ct DOB: 12/14/1960 SSN: ***-**-5575
Home Phone: (408) 319-7490 Work Phone:
City, State, Zip: Gilroy, CA 95020 Cell. Phone: (408) 888-6995 email:
Referring Phys:

Case: Right clavicle open reduction internal fixation ID: 6526 Date of Service: 03/09/2021
Case Provider: Reynolds, Kerisimasi Quick Code: Reynolds
Referring Physician: Reynolds, Kerisimasi Quick Code: Reynolds
Primary Diagnosis:
Emergency Contact: Phone:
Billing Group: United Healthcare Created: 02/11/19

Primary Guarantor
Name: Watts, Dennis Patient's Relationship: Self
Home Phone: (408) 319-7490 Work Phone:

Primary Insurance
Name: United Health Care Claim Office: United Health Care
Address 1: P.O. Box 740800 Address 2:
City, State, Zip: Atlanta, GA 30374 Phone: (877) 842-3210 Fax:
Insured ID: 942101831 Group Name : Group Number: 904871
Insured Name: Watts, Dennis Patient's Relationship: Self Copay :
DOB, SSN: 12/14/1960 ***-**-5575 Emp:
Procedures
Procedure Body Side Surgeon
DX 1 DX 2 DX 3 DX 4
OPEN TX CLAVICULAR FRACTURE INTERNAL FIXATION [23515] Right Reynolds, Kerisimasi

I have read the above document and certify that all information is current and correct.

_________________________________________ _____________ _________________________________________

patient/responsible party date witness

07:48 AM 03/10/21 created by amkaiSolutions.com

amkai-reports-core-rep 3.17.1.0.0
Precision Surgicenter Patient Summary Information
with proc w sig
39180 FARWELL DRIVE (510) 494-0800
Fremont, CA 94538

Patient: Kochel, Michael Sex: Male Account: 4753

Address: 2590 Marina Blvd DOB: 04/16/1987 SSN:
Home Phone: (510) 931-0273 Work Phone:
City, State, Zip: San Leandro, CA 94577 Cell. Phone: (510) 309-9160 email:
Referring Phys:
Right shoulder arthroscopy with capsulorrhaphy, bankart repair, possible ID: 6336 Date of Service: 03/09/2021
Case: platelet rich
Case Provider: Reynolds, Kerisimasi Quick Code: Reynolds
Referring Physician: Reynolds, Kerisimasi Quick Code: Reynolds
Primary Diagnosis:
Emergency Contact: Phone:
Billing Group: Alameda Alliance Created: 12/31/20

Primary Guarantor
Name: Kochel, Michael Patient's Relationship: Self
Home Phone: (510) 931-0273 Work Phone:

Primary Insurance
Name: Alameda Alliance Claim Office: Alameda Alliance
Address 1: P.O. Box 2460 Address 2:
City, State, Zip: Alameda, CA 94501 Phone: (510) 747-4505 Fax:
Insured ID: 000195747 Group Name : Group Number:
Insured Name: Kochel, Michael Patient's Relationship: Self Copay :
DOB, SSN: 04/16/1987 Emp:
Procedures
Procedure Body Side Surgeon
DX 1 DX 2 DX 3 DX 4
ARTHROSCOPY SHOULDER SURGICAL CAPSULORRHAPHY [29806] Right Reynolds, Kerisimasi

CAPSULORRHAPHY ANTERIOR W/LABRAL REPAIR [23455] Right Reynolds, Kerisimasi

I have read the above document and certify that all information is current and correct.

_________________________________________ _____________ _________________________________________

patient/responsible party date witness

07:48 AM 03/10/21 created by amkaiSolutions.com

Precision Surgicenter Patient Summary Information
with proc w sig
39180 FARWELL DRIVE (510) 494-0800
Fremont, CA 94538

Patient: Loy, Ethan Sex: Male Account: 4865

Address: 1505 Haven Lane DOB: 12/26/1995 SSN:
Home Phone: (714) 290-7596 Work Phone:
City, State, Zip: Santa Ana, CA 92703 Cell. Phone: email:
Referring Phys:
Left knee arthroscopy achilles allograft anterior cruciate ligament ID: 6502 Date of Service: 03/09/2021
Case: reconstruction, possible
Case Provider: Reynolds, Kerisimasi Quick Code: Reynolds
Referring Physician: Reynolds, Kerisimasi Quick Code: Reynolds
Primary Diagnosis:
Emergency Contact: Phone:
Billing Group: Global One Created: 03/04/21

Primary Guarantor
Name: Loy, Ethan Patient's Relationship: Self
Home Phone: (714) 290-7596 Work Phone:

Primary Insurance
Name: Global One Ventures, LLC Claim Office: Global One Ventures, LLC
Address 1: 6125 Paseo Del Norte Suite 210 Address 2:
City, State, Zip: Carlsbad, CA 92011 Phone: (760) 602-7872 Fax: (760) 602-7873
Insured ID: XEK910458172 Group Name : Group Number:
Insured Name: Loy, Ethan Patient's Relationship: Self Copay :
DOB, SSN: 12/26/1995 Emp:
Procedures
Procedure Body Side Surgeon
DX 1 DX 2 DX 3 DX 4
ARTHRS AIDED ANT CRUCIATE LIGM RPR/AGMNTJ/RCNSTJ [29888] Reynolds, Kerisimasi

LIGAMENTOUS RECONSTRUCTION KNEE EXTRA-ARTICULAR [27427] Reynolds, Kerisimasi

ARTHROSCOPY KNEE W/MENISCUS RPR MEDIAL/LATERAL [29882] Reynolds, Kerisimasi

NJX PLTLT PLASMA W/IMG HARVEST/PREPARATION [0232T] Reynolds, Kerisimasi

I have read the above document and certify that all information is current and correct.

_________________________________________ _____________ _________________________________________

patient/responsible party date witness

07:48 AM 03/10/21 created by amkaiSolutions.com

Precision Surgicenter Patient Summary Information
with proc w sig
39180 FARWELL DRIVE (510) 494-0800
Fremont, CA 94538

Patient: Alakozai, Maryam Sex: Female Account: 4859

Address: 270 Bryant Cmn DOB: 06/06/1983 SSN:
Home Phone: (707) 332-3998 Work Phone:
City, State, Zip: Fremont, CA 94539 Cell. Phone: email:
Referring Phys:

Case: Right knee diagnostic arthroscopy with possible synovectomy ID: 6494 Date of Service: 03/09/2021
Case Provider: Reynolds, Kerisimasi Quick Code: Reynolds
Referring Physician: Reynolds, Kerisimasi Quick Code: Reynolds
Primary Diagnosis:
Emergency Contact: Phone:
Billing Group: Alameda Alliance Created: 03/02/21

Primary Guarantor
Name: Alakozai, Maryam Patient's Relationship: Self
Home Phone: (707) 332-3998 Work Phone:

Primary Insurance
Name: Alameda Alliance Claim Office: Alameda Alliance
Address 1: P.O. Box 2460 Address 2:
City, State, Zip: Alameda, CA 94501 Phone: (510) 747-4505 Fax:
Insured ID: 000228123 Group Name : Group Number:
Insured Name: Alakozai, Maryam Patient's Relationship: Self Copay :
DOB, SSN: 06/06/1983 Emp:
Procedures
Procedure Body Side Surgeon
DX 1 DX 2 DX 3 DX 4
ARTHROSCOPY KNEE SYNOVECTOMY LIMITED SPX [29875] Right Reynolds, Kerisimasi

ARTHROSCOPY KNEE DIAGNOSTIC W/WO SYNOVIAL BX SPX [29870] Reynolds, Kerisimasi

I have read the above document and certify that all information is current and correct.

_________________________________________ _____________ _________________________________________

patient/responsible party date witness

07:48 AM 03/10/21 created by amkaiSolutions.com