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Text File  |  1995-06-28  |  10KB  |  311 lines
  1. 266
  2. Patient Number,0,2,8,0
  3. Patient Name,0,10,30,0
  4. Patient First Name,8,10,30,0
  5. Patient Middle Name/Initial,9,10,30,0
  6. Patient Last Name,10,10,30,0
  7. Patient Street,0,40,30,0
  8. Patient Cityline,4,70,32,0
  9. Patient City,0,70,20,0
  10. Patient State,0,90,2,0
  11. Patient Zip Code,0,92,10,0
  12. Patient Phone #1,3,102,10,0
  13. Patient Phone #2,3,112,10,0
  14. Patient Social Security #,5,122,10,0
  15. Patient Sex,0,221,1,0
  16. Patient Birthdate,11,222,8,0
  17. Patient Date Of Last Payment,2,232,6,0
  18. Patient Amount Of Last Payment,6,434,7,0
  19. Patient Billing Code,0,238,1,0
  20. Patient Indicator,0,239,5,0
  21. Patient Balance Forward Date,2,441,6,0
  22. 30 Day Balance Forward,6,457,9,0
  23. 60 Day Balance Forward,6,466,9,0
  24. 90 Day Balance Forward,6,475,9,0
  25. Patient Balance,7,246,10,0
  26. Patient Price Indicator,0,338,1,0
  27. Patient Marital Status,0,447,1,0
  28. Primary Accept Assignment,0,266,1,0
  29. Patient Signature On File,0,456,1,0
  30. Provider Number,14,244,2,0
  31. Provider Name,0,1,30,4
  32. Provider SS#,12,103,9,4
  33. Provider Licence#,0,112,15,4
  34. Provider Sig On File,0,127,1,4
  35. Patient Employer Address #,0,184,5,0
  36. Patient Employer Name,0,7,30,3
  37. Patient Employer Street,0,37,30,3
  38. Patient Employer Cityline,4,67,32,3
  39. Patient Employer Phone,3,99,10,3
  40. Primary H.O.H. Chart,0,132,8,0
  41. Primary Name,0,10,30,1
  42. Primary Street,0,40,30,1
  43. Primary Cityline,4,70,32,1
  44. Primary Phone #1,3,102,10,1
  45. Primary Social Security #,5,122,10,1
  46. Primary Billing Code,0,238,1,1
  47. Primary Indicator,0,239,5,1
  48. Primary Relationship,0,140,1,0
  49. Primary Insurance Number,0,159,4,0
  50. Primary Insurance Name,0,1,30,5
  51. Primary Insurance Street,0,31,30,5
  52. Primary Insurance Cityline,4,61,32,5
  53. Primary Insurance Phone,3,93,10,5
  54. Primary Insurance Contact,0,103,18,5
  55. Primary Policy Number,0,269,20,0
  56. Primary Group Number,0,289,20,0
  57. Primary Sig. On File,0,456,1,1
  58. Reserved For Future Use,0,455,2,0
  59. Primary Percent Coverage (A),0,309,3,0
  60. Primary Percent Coverage (B),0,485,3,0
  61. Primary Percent Coverage (C),0,491,3,0
  62. Primary Percent Coverage (D),0,497,3,0
  63. Primary Percent Coverage (E),0,503,3,0
  64. Primary Percent Coverage (F),0,509,3,0
  65. Primary Percent Coverage (G),0,515,3,0
  66. Primary Percent Coverage (H),0,521,3,0
  67. Secondary H.O.H. Chart,0,141,8,0
  68. Secondary Name,0,10,30,2
  69. Secondary Street,0,40,30,2
  70. Secondary Cityline,4,70,32,2
  71. Secondary Phone #1,3,102,10,2
  72. Secondary Social Security #,5,122,10,2
  73. Secondary Billing Code,0,238,1,2
  74. Secondary Indicator,0,239,5,2
  75. Secondary Relationship,0,149,1,0
  76. Secondary Insurance Number,0,163,4,0
  77. Secondary Insurance Name,0,1,30,6
  78. Secondary Insurance Street,0,31,30,6
  79. Secondary Insurance Cityline,4,61,32,6
  80. Secondary Insurance Phone,3,93,10,6
  81. Secondary Insurance Contact,0,103,18,6
  82. Secondary Policy Number,0,315,20,0
  83. Secondary Group Number,0,576,20,0
  84. Second Insured Sig. On File,0,456,1,2
  85. Secondary Percent Coverage (A),0,335,3,0
  86. Secondary Percent Coverage (B),0,488,3,0
  87. Secondary Percent Coverage (C),0,494,3,0
  88. Secondary Percent Coverage (D),0,500,3,0
  89. Secondary Percent Coverage (E),0,506,3,0
  90. Secondary Percent Coverage (F),0,512,3,0
  91. Secondary Percent Coverage (G),0,518,3,0
  92. Secondary Percent Coverage (H),0,524,3,0
  93. Referral Source Address Code,0,429,5,0
  94. Referral Source Name,0,7,30,7
  95. Referral Source Street,0,37,30,7
  96. Referral Source Cityline,4,67,32,7
  97. Referral Source Phone,3,99,10,7
  98. Referral Source Type,0,129,1,7
  99. Facility Address Code,0,339,5,0
  100. Facility Name,0,7,30,8
  101. Facility Street,0,37,30,8
  102. Facility Cityline,4,67,32,8
  103. Facility Phone,3,99,10,8
  104. Reserved For Future Use,0,450,1,0
  105. Reserved For Future Use,0,344,1,0
  106. Pat. Related to Employment?,0,345,1,0
  107. Patient Related to Accident?,0,346,1,0
  108. Patient Same/Similar Symtoms,0,347,1,0
  109. Patient Emergency?,0,348,1,0
  110. Patient EPSDT,0,349,1,0
  111. Patient Family Planning,0,350,1,0
  112. Patient Lab Work Performed?,0,351,1,0
  113. Patient Lab Charges,6,352,7,0
  114. Pat. Date Injury/Illness/LMP,2,359,6,0
  115. Patient First Consulted Date,2,365,6,0
  116. Patient Date Able For Work,2,371,6,0
  117. Pat. Date Total Disabl Frm,2,377,6,0
  118. Pat. Date Total Disabl To,2,383,6,0
  119. Pat. Date Partial Disabl Frm,2,389,6,0
  120. Pat. Date Partial Disabl To,2,395,6,0
  121. Pat. Date Hospitalization Frm,2,401,6,0
  122. Pat. Date Hospitalization To,2,407,6,0
  123. Pat. Prior Authorization #,0,413,15,0
  124. Reserved For Future Use,0,425,2,0
  125. Patient Employment Status,0,448,1,0
  126. Patient Student Status,0,449,1,0
  127. Patient Death Indicator,0,450,1,0
  128. Patient First Symptoms Ind.,0,451,1,0
  129. Patient Employer Location,0,215,6,0
  130. Patient Allergies/Notes,0,529,47,0
  131. Provider Medicare PIN,0,128,20,4
  132. Provider Medicaid PIN,0,148,20,4
  133. Provider CHAMPUS PIN,0,168,20,4
  134. Provider BC/BS PIN,0,188,20,4
  135. Provider Commercial PIN,0,208,20,4
  136. Patient Accident State,0,596,2,0
  137. Pat. Date Of Similar Symptoms,2,598,6,0
  138. Pat. Date Unable Work From,2,604,6,0
  139. Pat. Medicaid Resubmission #,0,610,12,0
  140. Pat. Medicaid Org. Reference,0,622,18,0
  141. Patient Local Use Field (A),0,640,20,0
  142. Patient Local Use Field (B),0,660,50,0
  143. Attorney Address Code,0,172,5,0
  144. Attorney City,0,67,20,10
  145. Attorney Cityline,4,67,32,10
  146. Attorney Contact,0,109,20,10
  147. Attorney Fax Phone,3,170,10,10
  148. Attorney ID,0,130,20,10 
  149. Attorney Phone,3,99,10,10
  150. Attorney Name,0,7,30,10
  151. Attorney State,0,87,2,10
  152. Attorney Street,0,37,30,10
  153. Attorney Zip Code,0,89,10,10
  154. CHAMPUS Branch Of Service,0,837,1,0
  155. CHAMPUS Card Effective Date,2,844,6,0
  156. CHAMPUS Non-Availability ID,0,836,1,0
  157. CHAMPUS Program of Disabled,0,841,2,0
  158. CHAMPUS Sponsor Grade,0,838,2,0
  159. CHAMPUS Sponsor Status,0,840,1,0
  160. CHAMPUS Termination Date,2,850,6,0
  161. Facility City,0,67,20,8
  162. Facility Contact,0,109,20,8
  163. Facility Fax Phone,3,170,10,8
  164. Facility ID,0,130,20,8 
  165. Facility State,0,87,2,8
  166. Facility Zip Code,0,89,10,8
  167. Patient Authorized # of Visits,0,864,2,0
  168. Patient Chart is A Patient,0,183,1,0
  169. Patient Co-payment Amount,6,774,7,0
  170. Patient Credit Card Name,0,781,30,0
  171. Patient Credit Card Number,0,811,20,0
  172. Patient Credit Card Exp Date,0,831,4,0
  173. Patient Country,0,882,10,0
  174. Patient Current Visit Number,0,862,2,0
  175. Patient Date of Last X-ray,2,951,6,0
  176. Patient Default Diagnosis #1,0,896,10,0
  177. Patient Default Diagnosis #2,0,906,10,0
  178. Patient Default Diagnosis #3,0,916,10,0
  179. Patient Default Diagnosis #4,0,926,10,0
  180. Patient Emp Retirement Date,2,189,6,0
  181. Patient Employer ID,0,130,20,3
  182. Patient Last Visit Date,2,856,6,0
  183. Patient Sublux/Diag Desc,0,936,15,0
  184. Patient Other Arrangements,0,452,4,0
  185. Pat. Prim Policy Capitation,0,171,1,0
  186. Patient Second ID#,0,195,15,0
  187. Patient Start Date,2,177,6,0
  188. Patient Visit Series Auth #,0,866,15,0
  189. Patient Visit Series ID,0,881,1,0
  190. Pat. Wkmn's Comp Ret to Work,0,892,1,0
  191. Pat. Wkmn's Comp % Perm Disabl,0,893,3,0
  192. Patient Work Phone,3,957,10,0
  193. Patient Work Phone Extension,0,967,4,0
  194. Print Patient Statement (Y/N),0,344,1,0
  195. Practice City,0,61,20,14
  196. Practice State,0,81,2,14
  197. Practice Zip Code,0,83,10,14
  198. Primary Ins Address #2,0,234,30,5
  199. Primary Insurance City,0,61,20,5
  200. Primary Insurance Fax Phone,3,203,10,5
  201. Primary Insurance State,0,81,2,5
  202. Primary Insurance Zip Code,0,83,10,5
  203. Provider UPIN,0,263,20,4
  204. Referral Source City,0,67,20,7
  205. Referral Source Contact,0,109,20,7
  206. Referral Source Fax Phone,3,170,10,7
  207. Referral Source ID,0,130,20,7 
  208. Referral Source State,0,87,2,7
  209. Referral Source Zip Code,0,89,10,7
  210. Referring Provider Address #,0,210,5,0
  211. Referring Provider City,0,67,20,11
  212. Referring Provider Cityline,4,67,32,11
  213. Referring Provider Contact,0,109,20,11
  214. Referring Provider Fax Phone,3,170,10,11
  215. Referring Provider ID,0,130,20,11
  216. Referring Provider Name,0,7,30,11
  217. Referring Provider Phone,3,99,10,11
  218. Referring Provider Street,0,37,30,11
  219. Referring Provider State,0,87,2,11
  220. Referring Provider Zip Code,0,89,10,11
  221. Secondary Accept Assignment,0,267,1,0
  222. Secondary HOH Birthdate,11,222,8,2
  223. Secondary HOH City,0,70,20,2
  224. Secondary HOH State,0,90,2,2
  225. Secondary HOH Zip Code,0,92,10,2
  226. Secondary Ins Address #2,0,234,30,6
  227. Secondary Insurance City,0,61,20,6
  228. Secondary Insurance Fax Phone,3,203,10,6
  229. Secondary Insurance State,0,81,2,6
  230. Secondary Insurance Zip Code,0,83,10,6
  231. Tertiary Accept Assignment,0,268,1,0
  232. Tertiary HOH Billing Code,0,238,1,12
  233. Tertiary HOH Birthdate,11,222,8,12
  234. Tertiary HOH Chart,0,150,8,0
  235. Tertiary HOH Chart a Patient,0,183,1,12
  236. Tertiary HOH City,0,70,20,12
  237. Tertiary HOH Cityline,4,70,32,12
  238. Tertiary HOH Indicator,0,239,5,12
  239. Tertiary HOH Name,0,10,30,12
  240. Tertiary HOH Phone #1,3,102,10,12
  241. Tertiary HOH Relationship,0,158,1,0
  242. Tertiary HOH Social Security #,5,122,10,12
  243. Tertiary HOH State,0,90,2,12
  244. Tertiary HOH Street,0,40,30,12
  245. Tertiary HOH Zip Code,0,92,10,12
  246. Tertiary Insured Sig. On File,0,456,1,12
  247. Tertiary Ins Address #2,0,234,30,13
  248. Tertiary Insurance City,0,61,20,13
  249. Tertiary Insurance Cityline,4,61,32,13
  250. Tertiary Insurance Contact,0,103,18,13
  251. Tertiary Insurance Fax Phone,3,203,10,13
  252. Tertiary Insurance Group #,0,730,20,0
  253. Tertiary Insurance Name,0,1,30,13
  254. Tertiary Insurance Number,0,167,4,0
  255. Tertiary Insurance Phone,3,93,10,13
  256. Tertiary Insurance Policy #,0,710,20,0
  257. Tertiary Insurance State,0,81,2,13
  258. Tertiary Insurance Street,0,31,30,13
  259. Tertiary Insurance Zip Code,0,83,10,13
  260. Tertiary Percent Coverage (A),0,750,3,0
  261. Tertiary Percent Coverage (B),0,753,3,0
  262. Tertiary Percent Coverage (C),0,756,3,0
  263. Tertiary Percent Coverage (D),0,759,3,0
  264. Tertiary Percent Coverage (E),0,762,3,0
  265. Tertiary Percent Coverage (F),0,765,3,0
  266. Tertiary Percent Coverage (G),0,768,3,0
  267. Tertiary Percent Coverage (H),0,771,3,0
  268. 14
  269. 1,39
  270. 1,66
  271. 4,34
  272. 6,29
  273. 5,48
  274. 5,75
  275. 4,92
  276. 4,98
  277. 4,130
  278. 4,142
  279. 4,209
  280. 1,233
  281. 5,253
  282. 7,
  283. 27
  284. ,2,,
  285. ,1,,16
  286. ,13,,
  287. ,14,,
  288. ,15,,
  289. ,16,,
  290. Employers,17,,
  291. Employer Location,-6,,
  292. ,5,,
  293. Birth Dates,27,,
  294. Referral Sources,17,,
  295. Referred By Type,10,,
  296. 1st Ins Carriers,18,,
  297. 2nd Ins Carriers,18,,
  298. Last Payment Dates,11,,
  299. Balances Due,22,,
  300. Facilities,17,,
  301. Primary Accept Assignment,4,,
  302. ,6,,
  303. Print Head Of HouseHolds Only,3,,N
  304. Patient Name Match,-30,,
  305. 3rd Ins Carriers,18,,
  306. Secondary Accept Assignment,4,,
  307. Tertiary Accept Assignment,4,,
  308. Last Visit Dates,11,,
  309. New Patient Dates,11,,
  310. Patients Only,3,,
  311.