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Text File  |  1996-01-22  |  17KB  |  935 lines
  1. "Format File Version 9"
  2. "HCFA-1500(12-90)"
  3. 184
  4. ""
  5. 1,46,"ñ╒","XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX",0,1
  6. PRINTINS="Y"
  7. INAME
  8. "#E⌐ñY╒","%|"
  9. ""
  10. 2,46,"ñ╒","XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX",0,1
  11. PRINTINS="Y"
  12. ISTREET
  13. "#E⌐ñY╒","%}"
  14. ""
  15. 3,46,"ñ╒","XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX",0,1
  16. PRINTINS="Y"
  17. ICITYLN
  18. "#E⌐ñY╒","%~"
  19. ""
  20. 4,2,"ñ╒","X",0,2
  21. ICURINS="Secondary"
  22. "S"
  23. "%v⌐ñSecondary╒","ñS╒"
  24. ICURINS="Tertiary"
  25. "T"
  26. "%v⌐ñTertiary╒","ñT╒"
  27. ""
  28. 7,2,"ñ╒","X",0,1
  29. ITYPE="M"
  30. "X"
  31. "%{⌐ñM╒","ñX╒"
  32. ""
  33. 7,9,"ñ╒","X",0,1
  34. ITYPE="A"
  35. "X"
  36. "%{⌐ñA╒","ñX╒"
  37. ""
  38. 7,16,"ñ╒","X",0,1
  39. ITYPE="C"
  40. "X"
  41. "%{⌐ñC╒","ñX╒"
  42. ""
  43. 7,25,"ñ╒","X",0,1
  44. ITYPE="V"
  45. "X"
  46. "%{⌐ñV╒","ñX╒"
  47. ""
  48. 7,32,"ñ╒","X",0,1
  49. ITYPE="G" OR ITYPE="H" OR ITYPE="P"
  50. "X"
  51. "%{⌐ñG╒░%{⌐ñH╒░%{⌐ñP╒","ñX╒"
  52. ""
  53. 7,40,"ñ╒","X",0,1
  54. ITYPE="F"
  55. "X"
  56. "%{⌐ñF╒","ñX╒"
  57. ""
  58. 7,46,"ñ╒","X",0,1
  59. ITYPE="B" OR ITYPE="O" OR ITYPE="W"
  60. "X"
  61. "%{⌐ñB╒░%{⌐ñO╒░%{⌐ñW╒","ñX╒"
  62. IPOLICY
  63. 7,51,"%å","XXXXXXXXXXXXXXXXXXXX",0,0
  64. NAME
  65. 9,2,"#W","XXXXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
  66. LEFT(BDAY,4)
  67. 9,32,"▓#eºÑ4╒¿","XX XX",0,0
  68. RIGHT(BDAY,2)
  69. 9,38,"│#eºÑ2╒¿","XX",0,0
  70. ""
  71. 9,43,"ñ╒","X",0,1
  72. SEX="M"
  73. "X"
  74. "#d⌐ñM╒","ñX╒"
  75. ""
  76. 9,48,"ñ╒","X",0,1
  77. SEX="F"
  78. "X"
  79. "#d⌐ñF╒","ñX╒"
  80. IHNAME
  81. 9,51,"&2","XXXXXXXXXXXXXXXXXXXXXXXXXXXX",0,2
  82. ICURINS="Primary" AND ITYPE="M"
  83. " "
  84. "%v⌐ñPrimary╒»%{⌐ñM╒","ñ ╒"
  85. ICURINS="Medicare"
  86. " "
  87. "%v⌐ñMedicare╒","ñ ╒"
  88. STREET
  89. 11,2,"#[","XXXXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
  90. ""
  91. 11,34,"ñ╒","X",0,1
  92. IHREL=1
  93. "X"
  94. "&@⌐Ñ1╒","ñX╒"
  95. ""
  96. 11,39,"ñ╒","X",0,1
  97. IHREL=2
  98. "X"
  99. "&@⌐Ñ2╒","ñX╒"
  100. ""
  101. 11,43,"ñ╒","X",0,1
  102. IHREL=3
  103. "X"
  104. "&@⌐Ñ3╒","ñX╒"
  105. ""
  106. 11,48,"ñ╒","X",0,1
  107. IHREL=4
  108. "X"
  109. "&@⌐Ñ4╒","ñX╒"
  110. IHSTREET
  111. 11,51,"&6","XXXXXXXXXXXXXXXXXXXXXXXXXXXX",0,2
  112. ICURINS="Primary" AND ITYPE="M"
  113. " "
  114. "%v⌐ñPrimary╒»%{⌐ñM╒","ñ ╒"
  115. ICURINS="Medicare"
  116. " "
  117. "%v⌐ñMedicare╒","ñ ╒"
  118. CITY
  119. 13,2,"#]","XXXXXXXXXXXXXXXXXXXX",0,0
  120. STATE
  121. 13,28,"#^","XX",0,0
  122. ""
  123. 13,36,"ñ╒","X",0,1
  124. MARITAL="S"
  125. "X"
  126. "$,⌐ñS╒","ñX╒"
  127. ""
  128. 13,42,"ñ╒","X",0,1
  129. MARITAL="M"
  130. "X"
  131. "$,⌐ñM╒","ñX╒"
  132. ""
  133. 13,48,"ñ╒","X",0,1
  134. MARITAL<>"S" AND MARITAL<>"M" AND MARITAL<>""
  135. "X"
  136. "$,¬ñS╒»$,¬ñM╒»$,¬ñ╒","ñX╒"
  137. IHCITY
  138. 13,51,"&8","XXXXXXXXXXXXXXXXXXXX",0,2
  139. ICURINS="Primary" AND ITYPE="M"
  140. " "
  141. "%v⌐ñPrimary╒»%{⌐ñM╒","ñ ╒"
  142. ICURINS="Medicare"
  143. " "
  144. "%v⌐ñMedicare╒","ñ ╒"
  145. IHSTATE
  146. 13,76,"&9","XX",0,2
  147. ICURINS="Primary" AND ITYPE="M"
  148. " "
  149. "%v⌐ñPrimary╒»%{⌐ñM╒","ñ ╒"
  150. ICURINS="Medicare"
  151. " "
  152. "%v⌐ñMedicare╒","ñ ╒"
  153. ZIP
  154. 15,2,"#_","XXXXXXXXXXXX",0,0
  155. "     "+PHONE
  156. 15,16,"ñ     ╒ª#a","XXXXXXXXXXXXXX",0,1
  157. LEFT(PHONE,1)="("
  158. MIDL(PHONE,2,3)+"  "+RIGHT(PHONE,8)
  159. "▓#aºÑ1╒¿⌐ñ(╒","┤#aºÑ2╒ºÑ3╒¿ªñ  ╒ª│#aºÑ8╒¿"
  160. ""
  161. 15,36,"ñ╒","X",0,2
  162. EMPLSTS="F"
  163. "X"
  164. "$-⌐ñF╒","ñX╒"
  165. EMPLSTS="P"
  166. "X"
  167. "$-⌐ñP╒","ñX╒"
  168. ""
  169. 15,42,"ñ╒","X",0,1
  170. STUDENT="F"
  171. "X"
  172. "$/⌐ñF╒","ñX╒"
  173. ""
  174. 15,48,"ñ╒","X",0,1
  175. STUDENT="P"
  176. "X"
  177. "$/⌐ñP╒","ñX╒"
  178. IHZIP
  179. 15,51,"&:","XXXXXXXXXXXX",0,2
  180. ICURINS="Primary" AND ITYPE="M"
  181. " "
  182. "%v⌐ñPrimary╒»%{⌐ñM╒","ñ ╒"
  183. ICURINS="Medicare"
  184. " "
  185. "%v⌐ñMedicare╒","ñ ╒"
  186. "     "+IHPHONE
  187. 15,66,"ñ     ╒ª&;","XXXXXXXXXXXXXX",0,5
  188. ICURINS="Primary" AND ITYPE="M"
  189. " "
  190. "%v⌐ñPrimary╒»%{⌐ñM╒","ñ ╒"
  191. ICURINS="Medicare"
  192. " "
  193. "%v⌐ñMedicare╒","ñ ╒"
  194. ICURINS="Primary" AND ITYPE<>"M" AND LEFT(IHPHONE,1)="("
  195. MIDL(IHPHONE,2,3)+" "+RIGHT(IHPHONE,8)
  196. "%v⌐ñPrimary╒»%{¬ñM╒»▓&;ºÑ1╒¿⌐ñ(╒","┤&;ºÑ2╒ºÑ3╒¿ªñ ╒ª│&;ºÑ8╒¿"
  197. ICURINS="Secondary" AND LEFT(IHPHONE,1)="("
  198. MIDL(IHPHONE,2,3)+" "+RIGHT(IHPHONE,8)
  199. "%v⌐ñSecondary╒»▓&;ºÑ1╒¿⌐ñ(╒","┤&;ºÑ2╒ºÑ3╒¿ªñ ╒ª│&;ºÑ8╒¿"
  200. ICURINS="Tertiary" AND LEFT(IHPHONE,1)="("
  201. MIDL(IHPHONE,2,3)+" "+RIGHT(IHPHONE,8)
  202. "%v⌐ñTertiary╒»▓&;ºÑ1╒¿⌐ñ(╒","┤&;ºÑ2╒ºÑ3╒¿ªñ ╒ª│&;ºÑ8╒¿"
  203. OHNAME
  204. 17,2,"&p","XXXXXXXXXXXXXXXXXXXXXXXXXXXX",0,1
  205. OTYPE="M"
  206. " "
  207. "&U⌐ñM╒","ñ ╒"
  208. IGROUP
  209. 17,51,"&#","XXXXXXXXXXXXXXXXXXXX",0,3
  210. ICURINS="Primary" AND ITYPE="M"
  211. "NONE"
  212. "%v⌐ñPrimary╒»%{⌐ñM╒","ñNONE╒"
  213. ICURINS="Medicare"
  214. "NONE"
  215. "%v⌐ñMedicare╒","ñNONE╒"
  216. ICURINS="Secondary" AND ITYPE="M"
  217. OGROUP
  218. "%v⌐ñSecondary╒»%{⌐ñM╒","&a"
  219. OPOLICY
  220. 19,2,"&`","XXXXXXXXXXXXX",0,1
  221. OTYPE="M"
  222. " "
  223. "&U⌐ñM╒","ñ ╒"
  224. OGROUP
  225. 19,16,"&a","XXXXXXXXXXXXXX",0,1
  226. OTYPE="M"
  227. " "
  228. "&U⌐ñM╒","ñ ╒"
  229. ""
  230. 19,36,"ñ╒","X",0,1
  231. RELTOEMPL="Y"
  232. "X"
  233. "#r⌐ñY╒","ñX╒"
  234. ""
  235. 19,42,"ñ╒","X",0,1
  236. RELTOEMPL="N" OR RELTOEMPL=""
  237. "X"
  238. "#r⌐ñN╒░#r⌐ñ╒","ñX╒"
  239. LEFT(IHBDAY,4)
  240. 19,55,"▓&=ºÑ4╒¿","XX XX",0,2
  241. ICURINS="Primary" AND ITYPE="M"
  242. " "
  243. "%v⌐ñPrimary╒»%{⌐ñM╒","ñ ╒"
  244. ICURINS="Medicare"
  245. " "
  246. "%v⌐ñMedicare╒","ñ ╒"
  247. RIGHT(IHBDAY,2)
  248. 19,61,"│&=ºÑ2╒¿","XX",0,2
  249. ICURINS="Primary" AND ITYPE="M"
  250. " "
  251. "%v⌐ñPrimary╒»%{⌐ñM╒","ñ ╒"
  252. ICURINS="Medicare"
  253. " "
  254. "%v⌐ñMedicare╒","ñ ╒"
  255. " "
  256. 19,69,"ñ ╒","X",0,3
  257. ICURINS="Primary" AND ITYPE<>"M" AND IHSEX="M"
  258. "X"
  259. "%v⌐ñPrimary╒»%{¬ñM╒»&>⌐ñM╒","ñX╒"
  260. ICURINS="Secondary" AND IHSEX="M"
  261. "X"
  262. "%v⌐ñSecondary╒»&>⌐ñM╒","ñX╒"
  263. ICURINS<>"Medicare" AND IHSEX="M"
  264. "X"
  265. "%v¬ñMedicare╒»&>⌐ñM╒","ñX╒"
  266. " "
  267. 19,76,"ñ ╒","X",0,3
  268. ICURINS="Primary" AND ITYPE<>"M" AND IHSEX="F"
  269. "X"
  270. "%v⌐ñPrimary╒»%{¬ñM╒»&>⌐ñF╒","ñX╒"
  271. ICURINS="Secondary" AND IHSEX="F"
  272. "X"
  273. "%v⌐ñSecondary╒»&>⌐ñF╒","ñX╒"
  274. ICURINS<>"Medicare" AND ITYPE<>"M" AND IHSEX="F"
  275. "X"
  276. "%v¬ñMedicare╒»%{¬ñM╒»&>⌐ñF╒","ñX╒"
  277. LEFT(OHBDAY,4)
  278. 21,3,"▓&{ºÑ4╒¿","XX XX",0,2
  279. OTYPE="M"
  280. " "
  281. "&U⌐ñM╒","ñ ╒"
  282. ONUM<1
  283. " "
  284. "&T½Ñ1╒","ñ ╒"
  285. RIGHT(OHBDAY,2)
  286. 21,9,"│&{ºÑ2╒¿","XX",0,2
  287. OTYPE="M"
  288. " "
  289. "&U⌐ñM╒","ñ ╒"
  290. ONUM<1
  291. " "
  292. "&T½Ñ1╒","ñ ╒"
  293. " "
  294. 21,19,"ñ ╒","X",0,2
  295. OHSEX="M" AND OTYPE<>"M" AND ONUM>1
  296. "X"
  297. "&|⌐ñM╒»&U¬ñM╒»&T¼Ñ1╒","ñX╒"
  298. OTYPE="M"
  299. " "
  300. "&U⌐ñM╒","ñ ╒"
  301. " "
  302. 21,25,"ñ ╒","X",0,2
  303. OHSEX="F" AND OTYPE<>"M" AND ONUM>1
  304. "X"
  305. "&|⌐ñF╒»&U¬ñM╒»&T¼Ñ1╒","ñX╒"
  306. OTYPE="M"
  307. " "
  308. "&U⌐ñM╒","ñ ╒"
  309. ""
  310. 21,36,"ñ╒","X",0,1
  311. RELTOACC="A"
  312. "X"
  313. "#s⌐ñA╒","ñX╒"
  314. ""
  315. 21,42,"ñ╒","X",0,1
  316. RELTOACC="N" OR RELTOACC="" OR RELTOACC="Y"
  317. "X"
  318. "#s⌐ñN╒░#s⌐ñ╒░#s⌐ñY╒","ñX╒"
  319. ACCSTATE
  320. 21,46,"#t","XX",0,0
  321. IENAME
  322. 21,51,"&G","XXXXXXXXXXXXXXXXXXXXXXXXXXXX",0,2
  323. ICURINS="Primary" AND ITYPE="M"
  324. " "
  325. "%v⌐ñPrimary╒»%{⌐ñM╒","ñ ╒"
  326. ICURINS="Medicare"
  327. " "
  328. "%v⌐ñMedicare╒","ñ ╒"
  329. OENAME
  330. 23,2,"&à","XXXXXXXXXXXXXXXXXXXXXXXXXXXX",0,1
  331. OTYPE="M"
  332. " "
  333. "&U⌐ñM╒","ñ ╒"
  334. ""
  335. 23,36,"ñ╒","X",0,1
  336. RELTOACC="Y"
  337. "X"
  338. "#s⌐ñY╒","ñX╒"
  339. ""
  340. 23,42,"ñ╒","X",0,1
  341. RELTOACC="N" OR RELTOACC="" OR RELTOACC="A"
  342. "X"
  343. "#s⌐ñN╒░#s⌐ñ╒░#s⌐ñA╒","ñX╒"
  344. IPLAN
  345. 23,51,"%à","XXXXXXXXXXXXXXXXXXXXXXXXXXXX",0,4
  346. ICURINS="Primary" AND ITYPE<>"M" AND IPLAN=""
  347. INAME
  348. "%v⌐ñPrimary╒»%{¬ñM╒»%à⌐ñ╒","%|"
  349. ICURINS="Primary" AND ITYPE="M"
  350. " "
  351. "%v⌐ñPrimary╒»%{⌐ñM╒","ñ ╒"
  352. ICURINS="Medicare"
  353. " "
  354. "%v⌐ñMedicare╒","ñ ╒"
  355. ICURINS="Secondary" AND IPLAN=""
  356. INAME
  357. "%v⌐ñSecondary╒»%à⌐ñ╒","%|"
  358. OPLAN
  359. 25,2,"&_","XXXXXXXXXXXXXXXXXXXXXXXXXXXX",0,2
  360. OPLAN="" AND OTYPE<>"M"
  361. ONAME
  362. "&_⌐ñ╒»&U¬ñM╒","&V"
  363. OTYPE="M"
  364. " "
  365. "&U⌐ñM╒","ñ ╒"
  366. LOCALA
  367. 25,31,"$;","XXXXXXXXXXXXXXXXX",0,0
  368. ""
  369. 25,53,"ñ╒","X",0,3
  370. ICURINS="Secondary"
  371. "X"
  372. "%v⌐ñSecondary╒","ñX╒"
  373. ICURINS="Primary" AND ONUM>0
  374. "X"
  375. "%v⌐ñPrimary╒»&T¼Ñ0╒","ñX╒"
  376. ICURINS="Medicare" AND ONUM>0
  377. "X"
  378. "%v⌐ñMedicare╒»&T¼Ñ0╒","ñX╒"
  379. ""
  380. 25,58,"ñ╒","X",0,2
  381. ICURINS="Primary" AND ONUM<1
  382. "X"
  383. "%v⌐ñPrimary╒»&T½Ñ1╒","ñX╒"
  384. ICURINS="Medicare" AND ONUM<1
  385. "X"
  386. "%v⌐ñMedicare╒»&T½Ñ1╒","ñX╒"
  387. SIGLINE
  388. 28,7,"#7","XXXXXXXXXXXXXXXXXXXXXXXXX",0,0
  389. INSDATE
  390. 28,37,"#5","XX-XX-XX",0,0
  391. ISIGLINE
  392. 28,56,"#:","XXXXXXXXXXXXXXXXXXXXXXX",0,0
  393. DATEINJ
  394. 31,3,"#|","XXXXXXXX",0,1
  395. MIDL(DATEINJ,3,1)="-"
  396. LEFT(DATEINJ,2)+" "+MIDL(DATEINJ,4,2)+" "+RIGHT(DATEINJ,2)
  397. "┤#|ºÑ3╒ºÑ1╒¿⌐ñ-╒","▓#|ºÑ2╒¿ªñ ╒ª┤#|ºÑ4╒ºÑ2╒¿ªñ ╒ª│#|ºÑ2╒¿"
  398. INJURY
  399. 31,25,"#}","X",0,0
  400. DATESYMP
  401. 31,38,"#v","XXXXXXXX",0,1
  402. MIDL(DATESYMP,3,1)="-"
  403. LEFT(DATESYMP,2)+" "+MIDL(DATESYMP,4,2)+" "+RIGHT(DATESYMP,2)
  404. "┤#vºÑ3╒ºÑ1╒¿⌐ñ-╒","▓#vºÑ2╒¿ªñ ╒ª┤#vºÑ4╒ºÑ2╒¿ªñ ╒ª│#vºÑ2╒¿"
  405. WORKFROM
  406. 31,55,"#","XXXXXXXX",0,1
  407. MIDL(WORKFROM,3,1)="-"
  408. LEFT(WORKFROM,2)+" "+MIDL(WORKFROM,4,2)+" "+RIGHT(WORKFROM,2)
  409. "┤#ºÑ3╒ºÑ1╒¿⌐ñ-╒","▓#ºÑ2╒¿ªñ ╒ª┤#ºÑ4╒ºÑ2╒¿ªñ ╒ª│#ºÑ2╒¿"
  410. DATEWORK
  411. 31,69,"#Ç","XXXXXXXX",0,1
  412. MIDL(DATEWORK,3,1)="-"
  413. LEFT(DATEWORK,2)+" "+MIDL(DATEWORK,4,2)+" "+RIGHT(DATEWORK,2)
  414. "┤#ǺÑ3╒ºÑ1╒¿⌐ñ-╒","▓#ǺÑ2╒¿ªñ ╒ª┤#ǺÑ4╒ºÑ2╒¿ªñ ╒ª│#ǺÑ2╒¿"
  415. ""
  416. 33,2,"ñ╒","XXXXXXXXXXXXXXXXXXXXXXXXXX",0,2
  417. ICURINS="Primary" AND ITYPE="M" AND ILABPRV<>""
  418. ILABPRV
  419. "%v⌐ñPrimary╒»%{⌐ñM╒»%w¬ñ╒","%w"
  420. RPTYPE="P"
  421. RPPNAME
  422. "$~⌐ñP╒","$r"
  423. ""
  424. 33,29,"ñ╒","XXXXXXXXXXXXXXXXXXXXX",0,2
  425. ICURINS="Primary" AND ITYPE="M" AND ILABPRV<>""
  426. ILABUPIN
  427. "%v⌐ñPrimary╒»%{⌐ñM╒»%w¬ñ╒","%x"
  428. RPTYPE="P"
  429. RPID
  430. "$~⌐ñP╒","${"
  431. HOSPFROM
  432. 33,55,"$#","XXXXXXXX",0,1
  433. MIDL(HOSPFROM,3,1)="-"
  434. LEFT(HOSPFROM,2)+" "+MIDL(HOSPFROM,4,2)+" "+RIGHT(HOSPFROM,2)
  435. "┤$#ºÑ3╒ºÑ1╒¿⌐ñ-╒","▓$#ºÑ2╒¿ªñ ╒ª┤$#ºÑ4╒ºÑ2╒¿ªñ ╒ª│$#ºÑ2╒¿"
  436. HOSPTO
  437. 33,69,"$$","XXXXXXXX",0,1
  438. MIDL(HOSPTO,3,1)="-"
  439. LEFT(HOSPTO,2)+" "+MIDL(HOSPTO,4,2)+" "+RIGHT(HOSPTO,2)
  440. "┤$$ºÑ3╒ºÑ1╒¿⌐ñ-╒","▓$$ºÑ2╒¿ªñ ╒ª┤$$ºÑ4╒ºÑ2╒¿ªñ ╒ª│$$ºÑ2╒¿"
  441. LOCALB
  442. 35,2,"$<","XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX",0,0
  443. ""
  444. 35,53,"ñ╒","X",0,1
  445. LABWORK="Y"
  446. "X"
  447. "#z⌐ñY╒","ñX╒"
  448. ""
  449. 35,58,"ñ╒","X",0,1
  450. LABWORK="N" OR LABWORK=""
  451. "X"
  452. "#z⌐ñN╒░#z⌐ñ╒","ñX╒"
  453. LABCHARGE
  454. 35,66,"#{","XXXXX.XX",1,0
  455. DIAG1
  456. 37,4,"%8╓","XXX.XXX",0,0
  457. DIAG3
  458. 37,32,"%8╪","XXX.XXX",0,0
  459. MAIDCODE
  460. 37,51,"$'","XXXXXXXXXX",0,0
  461. MAIDORG
  462. 37,62,"$(","XXXXXXXXXXXXXXXXX",0,0
  463. DIAG2
  464. 39,4,"%8╫","XXX.XXX",0,0
  465. DIAG4
  466. 39,32,"%8┘","XXX.XXX",0,0
  467. PRIORAUTH
  468. 39,51,"$%","XXXXXXXXXXXXXXX",0,0
  469. ""
  470. 42,72,"ñ╒","XXXXXXXXXXXXXXX",0,1
  471. IPRINTID="P"
  472. EPHYSNAME
  473. "&(⌐ñP╒","%\"
  474. DATE
  475. 43,2,"%;","XX XX XX",0,0
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