"':;?`{}“”„‚’ WARNING: Javascript injection attempt detected in source CDA document. Terminating WARNING: Potentially malicious content found in CDA document. Clinical Document Do NOT edit this HTML directly: it was generated via an XSLT transformation from a CDA Release 2 XML document. <xsl:value-of select="$title"/>

Logo
  • BACK TO TOP
  • DEMOGRAPHICS
  • AUTHORING DETAILS
  • Clinical Sections
  • SIGNATURES

Document Information

Document Identifier Document Created
Confidentiality Normal Restricted Very restricted

Author

-

Contact

Signed

at

Contact

Legal authenticator

at

Contact

Entered by

Contact

Encounter

Identifier
Type
Identifier
Date
From:
To:
Location
of ID:

Responsible Party

Contact

Document maintained by

Contact

 at   from  to

Service Event

-
In fulfillment of    

Informant

Contact

Contact

Information Recipient

Contact

Participant

from to

Contact

Patient Identifiers

About

Date of Birth
Sex
Race
Information not available
Ethnicity
Information not available

Contact

Emergency Contact

Contact

Next of Kin

Contact
Related document
Consent
SetId and Version SetId: Version:
, 



Cannot display the text

Section Author: ,

: table table-striped table-hover


is in the whitelist

WARNING: non-local image found . Removing. If you wish non-local images preserved please set the limit-external-images param to 'no'.

WARNING: non-local image found . Removing. If you wish non-local images preserved please set the limit-external-images param to 'no'.

signed intended signature required , Male Female Undifferentiated

, 

, 

<>
: ( )
<>
Primary Recipient: Secondary Recipient: Recipient: Tel Fax Web Mail Home URL Vacation Home Primary Home Work Place Pub Temporary Bad or Old {$code=' '?} affiliate agent assigned entity commissioning party contact emergency contact next of kin signing authority guardian guardian citizen covered party personal relationship care giver healthcare provider {$classCode=' '?} (Father) (Mother) (Natural parent) (Step parent) (Son) (Daughter) (Child) (Extended family member) (Neighbor) (Significant other) {$code/@code=' '?}
Facility ID ( ) Not available
First day of period reported
Last day of period reported
of ,

code: healthcare service accommodation account accession financial adjudication consent container registration clinical trial timepoint event disciplinary action encounter incident inform invoice element working list monitoring program care provision procedure registration review substance administration speciment treatment substitution transportation verification financial transaction primary performer performer verifier secondary performer (admitting physician) (anesthesist) (anesthesia nurse) (attending physician) (discharging physician) (first assistant surgeon) (midwife) (nurse assistant) (primary care physician) (primary surgeon) (rounding physician) (second assistant surgeon) (scrub nurse) (third assistant) (consulting provider) (primary care provider) (referring provider) (medical home provider) / / / , : no information invalid masked not applicable unknown other United States Social Security Number United States National Provider Identifier Alaska Driver's License Alabama Driver's License Arkansas Driver's License Arizona Driver's License California Driver's License Colorado Driver's License Connecticut Driver's License DC Driver's License Delaware Driver's License Florida Driver's License Georgia Driver's License Hawaii Driver's License Indiana Driver's License Iowa Driver's License Idaho Driver's License Illinois Driver's License Kansas Driver's License Kentucky Driver's License Louisiana Driver's License Massachusetts Driver's License Maryland Driver's License Maine Driver's License Michigan Driver's License Minnesota Driver's License Missouri Driver's License Mississippi Driver's License Montana Driver's License New York Driver's License North Carolina Driver's License North Dakota Driver's License Nebraska Driver's License New Hampshire Driver's License New Jersey Driver's License New Mexico Driver's License Nevada Driver's License Ohio Driver's License Oklahoma Driver's License Oregon Driver's License Pennsylvania Driver's License Rhode Island Driver's License South Carolina Driver's License South Dakota Driver's License Tennessee Driver's License Texas Driver's License Utah Driver's License Virginia Driver's License Vermont Driver's License Washington Driver's License Wisconsin Driver's License West Virginia Driver's License Wyoming Driver's License Identifier Type (HL7) Associated Pathology Medical Group ATMS AXESSON TRANSCRIPTION Axesson Word Doc Transcriptions CrossTx Dignity Health Medical Group Dignity Boulder Creek Dominican Santa Cruz Hospital Dignity Internal Medicine Dignity Pediatrics Joydip Bhattacharya Balance Health of Ben Lomond Edward T Bradbury MD A Prof. Corp Bayview Gastroenterology Peggy Chen, M.D. Central Coast Sleep Disorders Center Central Coast Oncology and Hematology Albert Crevello, MD Diabetes Health Center Foot Doctors of Santa Cruz Maria Granthom, M.D. Gastroenterology Harbor Medical Group Monterey Bay Gastroenterology Monterey Bay Urology No More Clipboard Plazita Medical Clinic Pajaro Valley Neurolgy Medical Associates Milan Patel, MD Santa Cruz Pulmonary Medical Group Rio Del Mar Medical Clinic Romo, Mary-Lou Santa Cruz Office Santa Cruz Ear Nose and Throat Medical Group Scotts Valley Medical Clinic Simkin, Josefa MD Vu, Thanh Bioreference Labs BSCA Claims Data CCSDC Cedar Medical Clinic Cedar Medical Clinic DIANON ANDREA EDWARDS MD Elysium Family Doctors of Santa Cruz Hurray, Alvie Hunter LABCORP LABCORP UNKNOWN Melissa Lopez-Bermejo, MD Monterey Bay Family Physicians Medtek Mirth Support Testing Facility NSIGHT NwHIN OrthoNorCal Pajaro Health Center Pajaro Valley Medical Clinic Pajaro Valley Personal Health PMG QUEST Radiology Medical Group Resneck-Sannes, L. David MD Salud Para La Gente SBWTest Quest Diagnostics SC Santa Cruz County Health Services Agency Santa Cruz County Mental Health SCHIEAUTH Santa Cruz HIE Santa Cruz Nephrology Medical Group, Inc Santa Cruz Surgery Center Quest Diagnostics SJ Stanford Lab Unknown Watsonville Community Hospital zzBAD_REFERENCE_FACILITY Meaningless identifier, not to be used for any actual entities. Examples only. Meaningless identifier, not to be used for any actual entities. Examples only. OID: