MEDICARE 
                                       P O BOX 555555

                                       American Fork, UT  84003-0002


                                                 123456789A

Patient, Bob B                01 01 70        X  Patient, Bob B

123 Main ST                     X                123 Main ST        

American Fork             UT      X              American Fork          UT

84003         801 555-5555                      84003          801 555-5555

Patient, Bob B

abc12345678                             X           01 01 70              X

01 01 70               X                X

                                        X         MEDICARE

BLUE CROSS BLUE SHIELD                             X



       SIGNATURE ON FILE             01/01/2013          SIGNATURE ON FILE


                             1G     a12345
Doctor Fake, OD                     1234567890

                                                        X

  365.71





 222222            11     11111              1       45 00   1      1234567890











 123456789        X   888888         X               45 00              45 00

                       DR FAKE & ASSOCIATES       DR FAKE & ASSOCIATES     
                       1111 FAKE STREET           1111 FAKE STREET   
 DR .FAKE, OD          AMERICAN FORK UT 84003     AMERICAN FORK UT 84003     
     01/01/2013        9876543210                 9876543210     1C 1111