------------------ MY HEALTHEVET PERSONAL HEALTH INFORMATION ------------ *************CONFIDENTIAL************* Produced by the Blue Button (v11.1) 01/10/2011 09:47 Name: MHVVETERAN, ONE A Date of Birth: 03/01/1948 ------------------------ DOWNLOAD REQUEST SUMMARY ----------------------- System Request Date/Time: 01/10/2011 09:47 AM CST User Request Type: Download only my selected data from My HealtheVet File Name: mhv_MHVVETERAN_20110110.txt Data Types Selected: My HealtheVet Account Summary Demographics VA Appointments (Future) VA Appointments (Limited to past 2 years) --------------------- MY HEALTHEVET ACCOUNT SUMMARY --------------------- Source: VA Authentication Status: Authenticated Authentication Date: 08/19/2010 Authentication Facility ID: 979 Authentication Facility Name: SLC10 TEST LAB VA Treating Facility Type ---------------------------- ----------- AUSTIN PSIM OTHER DAYT29 M&ROC ----------------------------- DEMOGRAPHICS ---------------------------- Source: Self-Entered First Name: ONE Middle Initial: A Last Name: MHVVETERAN Suffix: Alias: MHVVET Relationship to VA: Patient, Veteran, Employee Gender: Male Blood Type: AB+ Organ Donor: Yes Date of Birth: 03/01/1948 Marital Status: Married Current Occupation: Truck Driver Mailing Address: 123 Anywhere Road Mailing Address2: Apartment 123 Mailing City: Anywhere Mailing State: DC Mailing Country: United States Mailing Province: Mailing Zip/Postal Code: 00001 Alternate Address: Alternate Address2: Alternate City: Alternate State: Alternate Country: Alternate Province: Alternate Zip/Postal Code: Home Phone Number: 000-010-0101 Work Phone Number: 000-020-0202 Pager Number: 000-030-0303 Cell Phone Number: 000-040-0404 FAX Number: 000-050-0505 Email Address: mhvveteran@emailaddress.com Preferred Method of Contact: Email EMERGENCY CONTACTS Contact First Name: Two Contact Last Name: MHVVeteran Relationship: Home Phone Number: 000-010-0101 Work Phone Number: 000-060-0606 Extension: Cell Phone Number: 000-070-0707 Address Line 1: 123 Anywhere Road Address Line 2: Apartment 123 City: Anywhere State: DC Country: United States Province: Zip/Post Code: 00001 Email Address: twomhvveteran@domain.com Contact First Name: Three Contact Last Name: MHVVeteran Relationship: Home Phone Number: 000-010-0101 Work Phone Number: 000-080-0808 Extension: Cell Phone Number: 000-090-0909 Address Line 1: 123 Anywhere Road Address Line 2: Apartment 123 City: Anywhere State: DC Country: United States Province: Zip/Post Code: 00001 Email Address: threemhvveteran@domain.com --------------------------- VA APPOINTMENTS ----------------------------- Source: VA VA Past Appointments are limited to two years from the date of your download request. FUTURE APPOINTMENTS: -------------------- Date/Time: 10/13/2011 04:00 PM Location: DAYT29 TEST LAB Status: FUTURE Clinic: C&P CHRISTIE Phone Number: 3929 Type: Compensation and Pension Appointment Date/Time: 09/07/2011 11:00 AM Location: DAYT29 TEST LAB Status: NOT APPLICABLE Clinic: TELEPHONE CALLS/GERIATRICS Phone Number: 3742 Date/Time: 07/27/2011 02:00 PM Location: DAYT29 TEST LAB Status: FUTURE Clinic: DIABETIC-BURKE Phone Number: 800-123-1234 Note: This appointment has pre-appointment activity scheduled: Lab: 07/27/2011 10:00 AM Date/Time: 06/15/2011 01:00 PM Location: DAYT29 TEST LAB Status: FUTURE Clinic: DIABETIC-BURKE Phone Number: 800-123-1234 Note: This appointment has pre-appointment activity scheduled: Lab: 06/15/2011 08:00 AM EKG: 06/15/2011 10:30 AM X-Ray: 06/15/2011 09:00 AM Date/Time: 05/03/2011 11:00 AM Location: DAYT29 TEST LAB Status: NOT APPLICABLE Clinic: TELEPHONE CALLS/GERIATRICS Phone Number: 3742 Note: This appointment has pre-appointment activity scheduled: X-Ray: 05/03/2011 08:00 AM Date/Time: 03/15/2011 10:00 AM Location: MIDDLETOWN Status: CANCELLED Clinic: MD/DENTAL FOSTER Phone Number: 2449 Note: This appointment has pre-appointment activity scheduled: Lab: 03/15/2011 09:30 AM PAST APPOINTMENTS: -------------------- Date/Time: 01/06/2011 10:00 AM Location: DAYT29 TEST LAB Status: NOT APPLICABLE Clinic: PRP JOHNSON,C (GRP) Phone Number: 2188 Note: This appointment has pre-appointment activity scheduled: Lab: 01/06/2011 09:00 AM EKG: 01/06/2011 09:30 AM Date/Time: 01/03/2011 01:00 PM Location: DAYT29 TEST LAB Status: NOT APPLICABLE Clinic: PRP JOHNSON,C (GRP) Phone Number: 2188 Date/Time: 12/29/2010 10:00 AM Location: MIDDLETOWN Status: NOT APPLICABLE Clinic: MD/PODIATRY NGUYEN (Follow-Up) Phone Number: 5416 Date/Time: 08/30/2010 02:00 PM Location: DAYT29 TEST LAB Status: APPOINTMENT KEPT Clinic: TELEPHONE CALLS/GERIATRICS Phone Number: 3742 Date/Time: 07/14/2010 09:00 AM Location: MIDDLETOWN Status: NOT APPLICABLE Clinic: MD/PODIATRY NGUYEN (Follow-Up) Phone Number: 5416 -------------- END MY HEALTHEVET PERSONAL HEALTH INFORMATION ------------