Datasets:
unstructuredio
/
SCORE-Bench

Dataset card Data Studio Files
xet
 Community
2
text
stringlengths
0
2.18k
1. ENTER YOUR HEALTH INSURANCE COMPANY NAME, ADDRESS AND TELEPHONE NUMBER (include coverage through spouse or other person)
--------------------------------------------------- Unstructured Handwriting Begin
1-800-601-3372
--------------------------------------------------- Unstructured Redacted Text Begin
--------------------------------------------------- Unstructured Redacted Text End
AARP/United Healthcare 202 Hall’s Mill Rd. Stanton, NJ 08889
--------------------------------------------------- Unstructured Handwriting End
2. NAME OF POLICY HOLDER
--------------------------------------------------- Unstructured Handwriting Begin
Robert James Eckersley
--------------------------------------------------- Unstructured Handwriting End
3. POLICY NUMBER
--------------------------------------------------- Unstructured Handwriting Begin
B10586
--------------------------------------------------- Unstructured Handwriting End
4. GROUP CODE
--------------------------------------------------- Unstructured Handwriting Begin
001
--------------------------------------------------- Unstructured Handwriting End
5. ARE YOU ELIGIBLE FOR MEDICAID?
(Federal health insurance for low income adults)
[] YES
--------------------------------------------------- Unstructured Handwriting Begin
[x]
--------------------------------------------------- Unstructured Handwriting End
NO
6A. ARE YOU ENROLLED IN MEDICARE HOSPITAL INSURANCE PART A?
--------------------------------------------------- Unstructured Handwriting Begin
[x]
--------------------------------------------------- Unstructured Handwriting End
YES [] NO
6B. EFFECTIVE DATE
(MM/DD/YYYY)
--------------------------------------------------- Unstructured Handwriting Begin
01/01/2025
--------------------------------------------------- Unstructured Handwriting End
6C. MEDICARE NUMBER
--------------------------------------------------- Unstructured Handwriting Begin
1EG4-TE5-MK72
--------------------------------------------------- Unstructured Handwriting End
--------------------------------------------------- Unstructured Sub-Title Begin
SECTION IV - DEPENDENT INFORMATION (Use a separate sheet for additional dependents)
--------------------------------------------------- Unstructured Sub-Title End
1. SPOUSE'S NAME (Last, First, Middle Name)
--------------------------------------------------- Unstructured Handwriting Begin
Eckersley Janet Louse
--------------------------------------------------- Unstructured Handwriting End
1A. SPOUSE'S SOCIAL SECURITY NUMBER
--------------------------------------------------- Unstructured Handwriting Begin
658-06-7388
--------------------------------------------------- Unstructured Handwriting End
1B. SPOUSE'S DATE OF BIRTH (MM/DD/YYYY)
--------------------------------------------------- Unstructured Handwriting Begin
01/18/60
--------------------------------------------------- Unstructured Handwriting End
1C. SPOUSE'S SEX
[] MALE
--------------------------------------------------- Unstructured Handwriting Begin
[x]
--------------------------------------------------- Unstructured Handwriting End
FEMALE
1D. DATE OF MARRIAGE (MM/DD/YYYY)
--------------------------------------------------- Unstructured Handwriting Begin
05/30/80
--------------------------------------------------- Unstructured Handwriting End
1E. SPOUSE’S ADDRESS AND TELEPHONE NUMBER (Street, City, State, ZIP if different from Veteran’s)
____
2. CHILD'S NAME (Last, First, Middle Name)
____
2A. CHILD'S DATE OF BIRTH
(MM/DD/YYYY)
____
2B. CHILD'S SOCIAL SECURITY
NO. (999-99-9999)
____
2C. DATE CHILD BECAME YOUR DEPENDENT (MM/DD/YYYY)
____
2D. CHILD'S RELATIONSHIP TO YOU (Check one)
[] SON [] DAUGHTER [] STEPSON [] STEPDAUGHTER
____