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Text File  |  1995-12-18  |  22KB  |  546 lines
  1. Format File Version 8
  2. 478
  3. FORMNAME,Form Name,0,40,30,0
  4. AGEA,Aging A - Current Entries,8,70,10,0
  5. AGEB,Aging B - 30 Days Past Due,8,71,10,0
  6. AGEC,Aging C - 60 Days Past Due,8,72,10,0
  7. AGED,Aging D - 90 Days Past Due,8,73,10,0
  8. BALFOR,Total Balance Forward,8,74,10,0
  9. BFDATE,Balance Forward Date,1,75,6,0
  10. PASTDUE,Total Amount Past Due,8,76,10,0
  11. BALANCE,Total Family Balance,8,77,10,0
  12. CHARGES,Total Of Form's Charges,8,41,10,0
  13. PAYMENTS,Total Of Form's Payments,8,42,10,0
  14. TAX,Form Tax Amount,8,69,10,0
  15. DUE,Form Balance Due,8,43,10,0
  16. MAXTRANS,Max Transaction On This Form,14,44,3,0
  17. MAXDIAGS,Max Diagnoses On This Form,14,45,3,0
  18. NUMTRANS,Num Trans Printed On Form,14,46,3,0
  19. NUMDIAGS,Num Diags Printed On Form,14,47,3,0
  20. INSDATE,Date Of Insurance,1,48,6,0
  21. SYSDATE,Today's System Date,1,49,6,0
  22. SIGLINE,Patient Signature Line,0,50,30,0
  23. PSIGLINE,Provider Signature Line,0,51,30,0
  24. ASIGLINE,Attending Signature Line,0,52,30,0
  25. ISIGLINE,Insured Signature Line,0,53,30,0
  26. OSIGLINE,Other Signature Line,0,54,30,0
  27. BYATTEND,Print By Attending Provider,0,55,1,0
  28. PAUSE,Pause For Single Sheet Feed,0,56,1,0
  29. CROSSOVER,MEDIGAP Crossover Claims,0,57,1,0
  30. ALWAYSACC,Always Accept Assignment,0,58,1,0
  31. PRINTPAY,Print Payments On Forms,0,59,1,0
  32. PRIPAYDATE,Primary Ins Payment Date,1,84,6,0
  33. PARADIAG,Paragraph Diagnosis,0,60,1,0
  34. PRINTZERO,Print Zero Amount Entries,0,61,1,0
  35. PRACDOC,Practice Or Doctor Address,0,62,1,0
  36. PRINTINS,Print Insurance Address,0,63,1,0
  37. PRINTPRAC,Print Practice/Doctor Address,0,64,1,0
  38. CUSTOMA,Custom Field A,0,65,30,0
  39. CUSTOMB,Custom Field B,0,66,30,0
  40. CUSTOMC,Custom Field C,0,67,30,0
  41. CUSTOMD,Custom Field D,0,68,30,0
  42. PAGE,Form Page Number,0,78,2,0
  43. PRNAME,Practice Name,0,1,30,1
  44. PRSTREET,Practice Street,0,31,30,1
  45. PRCITYLN,Practice Cityline,3,61,32,1
  46. PRCITY,Practice City,0,61,20,1
  47. PRSTATE,Practice State,0,81,2,1
  48. PRZIP,Practice Zip Code,0,83,10,1
  49. PRPHONE,Practice Phone,2,93,10,1
  50. PRFEDID,Practice Tax ID Number,0,103,15,1
  51. NEWDATE,New Patient Date,1,177,6,2
  52. PATYN,Patient Chart a Patient (Y/N),0,183,1,2
  53. CHART,Patient Chart,0,2,8,2
  54. NAME,Patient Name,0,10,30,2
  55. FIRST,Patient First Name,9,10,30,2
  56. MIDDLE,Patient Middle Name,10,10,30,2
  57. LAST,Patient Last Name,11,10,30,2
  58. STREET,Patient Street,0,40,30,2
  59. CITYLN,Patient Cityline,3,70,32,2
  60. CITY,Patient City,0,70,20,2
  61. STATE,Patient State,0,90,2,2
  62. ZIP,Patient Zip Code,0,92,10,2
  63. COUNTRY,Patient Country,0,882,10,2
  64. PHONE,Patient Phone,2,102,10,2
  65. PHONETWO,Patient Phone 2,2,112,10,2
  66. SSN,Patient Social Security Num,4,122,10,2
  67. SEX,Patient Sex,0,221,1,2
  68. BDAY,Patient Birthday,16,222,8,2
  69. BILLCODE,Patient Billing Code,0,238,1,2
  70. INDIC,Patient Indicator,0,239,5,2
  71. PRIMCAP,Pat. Prim Policy Capitation,0,171,1,2
  72. WRKPHONE,Patient Work Phone,2,957,10,2
  73. WRKPHEXT,Patient Work Phone Extension,0,967,4,2
  74. COPAYMENT,Co-payment Amount,8,774,7,2
  75. CCNAME,Credit Card Name,0,781,30,2
  76. CCNUMBER,Credit Card Number,0,811,20,2
  77. CCEXPIRE,Credit Care Expiration Date,0,831,4,2
  78. PATID,Patient Second ID,0,195,15,2
  79. PRICE,Patient Price Code,0,338,1,2
  80. EMPLPLAN,Reserved for Future Use,0,344,1,2
  81. RELTOEMPL,Related To Employment?,0,345,1,2
  82. RELTOACC,Related To Accident?,0,346,1,2
  83. ACCSTATE,Accident State,0,596,2,2
  84. SYMPTOMS,Same Or Similar Symptoms?,0,347,1,2
  85. DATESYMP,Date Similar Symptoms,15,598,6,2
  86. EMERGENCY,Emergency?,0,348,1,2
  87. EPSDT,EPSDT?,0,349,1,2
  88. FAMPLAN,Family Planning?,0,350,1,2
  89. LABWORK,Labwork Performed?,0,351,1,2
  90. LABCHARGE,Lab Charges,7,352,7,2
  91. DATEINJ,Date Of Injury/Illness/LMP,15,359,6,2
  92. INJURY,Injury/Illness/LMP Indicator,0,451,1,2
  93. DATECON,Date Consulted,15,365,6,2
  94. WORKFROM,Date Unable Work From,15,604,6,2
  95. DATEWORK,Date Unable Work To,15,371,6,2
  96. WCRETIND,Workmans Comp Return to Work Ind,0,892,1,2
  97. WCPERMDI,Workmans Comp % Perm Disability,14,893,3,2
  98. TDISFROM,Date Total Disability From,15,377,6,2
  99. TDISTO,Date Total Disability To,15,383,6,2
  100. PDISFROM,Date Partial Disability From,15,389,6,2
  101. PDISTO,Date Partial Disability To,15,395,6,2
  102. HOSPFROM,Date Hospitalization From,15,401,6,2
  103. HOSPTO,Date Hospitalization To,15,407,6,2
  104. PRIORAUTH,Prior Authorization Num,0,413,15,2
  105. ALLERGYNT,Allergies/Notes,0,529,47,2
  106. MAIDCODE,Medicaid Resubmission Code,0,610,12,2
  107. MAIDORG,Medicaid Original Ref. No.,0,622,18,2
  108. OTHARRNG,Patient Other Arrangements,0,452,4,2
  109. LEVSUBX,Level of Subluxation,0,936,15,2
  110. LASTXRAY,Date of Last X-ray,1,951,6,2
  111. MARITAL,Marital Status,0,447,1,2
  112. EMPLSTS,Employment Status,0,448,1,2
  113. RETDATE,Patient Emp Retirement Date,1,189,6,2
  114. STUDENT,Student Status,0,449,1,2
  115. DEATH,Death Code,0,450,1,2
  116. ACCASSIGN,Accept Assignment #1,0,266,1,2
  117. ACASSIGNB,Accept Assignment #2,0,267,1,2
  118. ACASSIGNC,Accept Assignment #3,0,268,1,2
  119. SIG,Signature On File,0,456,1,2
  120. ELIGIBLE,Reserved for Future Use,0,484,1,2
  121. LASTVISIT,Last Visit Date,1,856,6,2
  122. CURSERIES,Current Series Visit Total,14,862,2,2
  123. ANVISITS,Authorized Number of Visits,14,864,2,2
  124. VISITANUM,Visit Series Authorization #,0,866,15,2
  125. VISITID,Visit Series ID,0,881,1,2
  126. LOCALA,Local Use Field (A),0,640,20,2
  127. LOCALB,Local Use Field (B),0,660,50,2
  128. PPHYS,Provider Number,14,244,2,2
  129. PNAME,Provider Name,0,1,30,9
  130. PSTREET,Provider Street,0,31,30,9
  131. PCITYLN,Provider Cityline,3,61,32,9
  132. PCITY,Provider City,0,61,20,9
  133. PSTATE,Provider State,0,81,2,9
  134. PZIP,Provider Zip Code,0,83,10,9
  135. PPHONE,Provider Phone,2,93,10,9
  136. PFTXIND,Provider Federal Tax Ind,0,238,1,9
  137. PSSN,Provider Social Security #,4,103,9,9
  138. PLICENSE,Provider License Number,0,112,15,9
  139. PSIG,Provider Signature (Y/N),0,127,1,9
  140. PGROUP,Provider Group Number,0,228,10,9
  141. PPIN,Provider PIN (Crnt Ins),0,80,20,0
  142. PMCPIN,Provider MediCare PIN,0,128,20,9
  143. PMAPIN,Provider MedicAid PIN,0,148,20,9
  144. PCHPIN,Provider CHAMPUS PIN,0,168,20,9
  145. PBCPIN,Provider BC/BS PIN,0,188,20,9
  146. PCMPIN,Provider Commercial PIN,0,208,20,9
  147. PMPPRV,Prv Medicare Participant (Y/N),0,239,1,9
  148. PSPEC,Provider Speciality,0,240,3,9
  149. PXTRAONE,Provider Extra One,0,243,10,9
  150. PXTRATWO,Provider Extra Two,0,253,10,9
  151. PUPIN,Provider UPIN,0,263,20,9
  152. FACILITY,Facility Address Code,0,339,5,2
  153. FNAME,Facility Name,0,7,30,10
  154. FSTREET,Facility Street,0,37,30,10
  155. FCITYLN,Facility Cityline,3,67,32,10
  156. FCITY,Facility City,0,67,20,10
  157. FSTATE,Facility State,0,87,2,10
  158. FZIP,Facility Zip Code,0,89,10,10
  159. FPHONE,Facility Phone Number,2,99,10,10
  160. FFAXPH,Facility Fax Phone,2,170,10,10
  161. FCONTACT,Facility Contact (ID #),0,109,20,10
  162. FID,Facility ID,0,130,20,10
  163. FEXTRAONE,Facility Extra One,0,150,10,10
  164. FEXTRATWO,Facility Extra Two,0,160,10,10
  165. FTYPE,Facility Address Type,0,129,1,10
  166. REFERRER,Referral Source Address Code,0,429,5,2
  167. RNAME,Referral Source Name,0,7,30,11
  168. RSTREET,Referral Source Street,0,37,30,11
  169. RCITYLN,Referral Source Cityline,3,67,32,11
  170. RCITY,Referral Source City,0,67,20,11
  171. RSTATE,Referral Source State,0,87,2,11
  172. RZIP,Referral Source Zip Code,0,89,10,11
  173. RPHONE,Referral Source Phone Number,2,99,10,11
  174. RFAXPH,Referral Source Fax Phone,2,170,10,11
  175. RCONTACT,Referral Source Contact,0,109,20,11
  176. RID,Referral Source ID,0,130,20,11
  177. REXTRAONE,Referral Source Extra One,0,150,10,11
  178. REXTRATWO,Referral Source Extra Two,0,160,10,11
  179. RTYPE,Referral Source Type,0,129,1,11
  180. RPADDR,Referring Prv Address Code,0,210,5,2
  181. RPPNAME,Referring Provider Name,0,7,30,15
  182. RPSTREET,Referring Provider Street,0,37,30,15
  183. RPCITYLN,Referring Provider Cityline,3,67,32,15
  184. RPCITY,Referring Provider City,0,67,20,15
  185. RPSTATE,Referring Provider State,0,87,2,15
  186. RPZIP,Referring Provider Zip Code,0,89,10,15
  187. RPPHONE,Referring Prv Phone Number,2,99,10,15
  188. RPFAXPH,Referring Provider Fax Phone,2,170,10,15
  189. RPCONTACT,Referring Prv Contact,0,109,20,15
  190. RPID,Referring Provider ID,0,130,20,15
  191. RPXTRAONE,Referring Prv Extra One,0,150,10,15
  192. RPXTRATWO,Referring Prv Extra Two,0,160,10,15
  193. RPTYPE,Referring Provider Type,0,129,1,15
  194. ATADDR,Attorney Address Code,0,172,5,2
  195. ATPNAME,Attorney Name,0,7,30,16
  196. ATSTREET,Attorney Street,0,37,30,16
  197. ATCITYLN,Attorney Cityline,3,67,32,16
  198. ATCITY,Attorney City,0,67,20,16
  199. ATSTATE,Attorney State,0,87,2,16
  200. ATZIP,Attorney Zip Code,0,89,10,16
  201. ATPHONE,Attorney Phone Number,2,99,10,16
  202. ATFAXPH,Attorney Fax Phone,2,170,10,16
  203. ATCONTACT,Attorney Contact,0,109,20,16
  204. ATID,Attorney ID,0,130,20,16
  205. ATEXTRONE,Attorney Extra One,0,150,10,16
  206. ATEXTRTWO,Attorney Extra Two,0,160,10,16
  207. ATTYPE,Attorney Type,0,129,1,16
  208. PEMPLOYER,Patient Employer Code,0,184,5,2
  209. PEFIELD,Patient Employer Field,0,184,5,2
  210. PENAME,Patient Employer Name,0,7,30,14
  211. PESTREET,Patient Employer Street,0,37,30,14
  212. PECITYLN,Patient Employer Cityline,3,67,32,14
  213. PECITY,Patient Employer City,0,67,20,14
  214. PESTATE,Patient Employer State,0,87,2,14
  215. PEZIP,Patient Employer Zip Code,0,89,10,14
  216. PELOC,Patient Employment Location,0,215,6,2
  217. PEPHONE,Patient Employer Phone,2,99,10,14
  218. PEFAXPH,Patient Employer Fax Phone,2,170,10,14
  219. PEID,Patient Employer ID,0,130,20,14
  220. PEXTRAONE,Patient Employer Extra One,0,150,10,14
  221. PEXTRATWO,Patient Employer Extra Two,0,160,10,14
  222. PETYPE,Patient Employer Address Type,0,129,1,14
  223. DIAG,Form Diagnosis Code,5,36,10,0
  224. DIAGDESC,Form Diagnosis Description,0,37,40,0
  225. DIAGLINE,Form Diag Code & Description,0,38,70,0
  226. DATE,Entry From Date,1,0,6,0
  227. TODATE,Entry To Date,1,1,6,0
  228. DOC,Entry Document Number,0,2,8,0
  229. CODETYPE,Entry Procedure Code Type,0,3,1,0
  230. CODE,Entry Procedure Code,0,8,12,0
  231. CODEONLY,Entry Procedure Code Only,12,9,10,0
  232. MODIF,Entry Procedure Modifier,0,4,6,0
  233. CODEA,Entry Procedure Code 1,0,10,12,0
  234. CODEONLYA,Entry Procedure Code Only 1,12,11,10,0
  235. MODIFA,Entry Modifier Only 1,0,5,2,0
  236. CODEB,Entry Procedure Code 2,0,12,12,0
  237. CODEONLYB,Entry Procedure Code Only 2,12,13,10,0
  238. MODIFB,Entry Modifier Only 2,0,6,2,0
  239. CODEC,Entry Procedure Code 3,0,14,12,0
  240. CODEONLYC,Entry Procedure Code Only 3,12,15,10,0
  241. MODIFC,Entry Modifier Only 3,0,7,2,0
  242. DESC,Entry Procedure Description,0,16,30,0
  243. POS,Entry Place Of Service,0,17,2,0
  244. TOS,Entry Type Of Service,0,18,3,0
  245. EDIAG,Entry Diagnosis Line,0,20,30,0
  246. DIAGPTR,Entry Diagnosis Pointer,0,21,4,0
  247. UNITS,Entry Units,0,22,3,0
  248. MINUTES,Entry Minutes,0,35,3,0
  249. AMOUNT,Entry Amount,7,23,9,0
  250. BILLDATE,Reserved,1,24,6,0
  251. PBILLDATE,Reserved,1,25,6,0
  252. SBILLDATE,Reserved,1,26,6,0
  253. MBILLDATE,Reserved,1,27,6,0
  254. PSBILLDATE,Reserved,1,32,6,0
  255. DDIAGA,Form Default Diagnosis #1,0,896,10,2
  256. DDIAGB,Form Default Diagnosis #2,0,906,10,2
  257. DDIAGC,Form Default Diagnosis #3,0,916,10,2
  258. DDIAGD,Form Default Diagnosis #4,0,926,10,2
  259. EPHYSNAME,Entry Attend Phys Last Name,11,28,30,0
  260. EPHYSPIN,Entry Attend Phys PIN,0,29,20,0
  261. APHYS,Form Attending Phys Num,0,79,2,0
  262. ANAME,Form Attending Name,0,1,30,13
  263. ASTREET,Form Attending Street,0,31,30,13
  264. ACITYLN,Form Attending Cityline,3,61,32,13
  265. ACITY,Form Attending City,0,61,20,13
  266. ASTATE,Form Attending State,0,81,2,13
  267. AZIP,Form Attending Zip Code,0,83,10,13
  268. APHONE,Form Attending Phone,2,93,10,13
  269. AFTXIND,Form Att Prv Fed Tax Ind,0,238,1,13
  270. ASSN,Form Attending Soc Sec #,4,103,9,13
  271. ALICENSE,Form Attending License Num,0,112,15,13
  272. ASIG,Form Attending Signature (Y/N),0,127,1,13
  273. AGROUP,Form Attending Group Number,0,228,10,13
  274. APIN,Form Attending PIN (Crnt Ins),0,83,20,0
  275. AMCPIN,Form Attending MediCare PIN,0,128,20,13
  276. AMAPIN,Form Attending MedicAid PIN,0,148,20,13
  277. ACHPIN,Form Attending CHAMPUS PIN,0,168,20,13
  278. ABCPIN,Form Attending BC/BS PIN,0,188,20,13
  279. ACMPIN,Form Attending Commercial PIN,0,208,20,13
  280. ASPEC,Form Att Prv Speciality,0,240,3,13
  281. AXTRAONE,Form Att Prv Extra One,0,243,10,13
  282. AXTRATWO,Form Att Prv Extra Two,0,253,10,13
  283. AUPIN,Form Att Prv UPIN,0,263,20,13
  284. AMPPRV,Form Att Prv MED Participant,0,239,1,13
  285. ICURINS,Current Ins (Pri-Sec-Ter),0,81,10,0
  286. ILABPRV,Form Inside Lab Att Prv Name,0,30,30,0
  287. ILABUPIN,Form Inside Lab Att Prv UPIN,0,31,20,0
  288. IADDRB,Insurance Address #2,0,234,30,3
  289. INUM,Insurance Number,14,277,4,3
  290. ITYPE,Insurance Type,0,172,1,3
  291. INAME,Insurance Name,0,1,30,3
  292. ISTREET,Insurance Street,0,31,30,3
  293. ICITYLN,Insurance Cityline,3,61,32,3
  294. ICITY,Insurance City,0,61,20,3
  295. ISTATE,Insurance State,0,81,2,3
  296. IZIP,Insurance Zip,0,83,10,3
  297. IPHONE,Insurance Phone,2,93,10,3
  298. IFAXPH,Insurance Fax Phone,2,203,10,3
  299. ICONTACT,Insurance Contact,0,103,18,3
  300. IPLAN,Insurance Plan Name,0,142,30,3
  301. IPOLICY,Insurance Policy,0,281,20,3
  302. IGROUP,Insurance Group,0,301,20,3
  303. ICODETYPE,Insurance Code Type Set,0,123,1,3
  304. ISIG,Insurance Signature (Y/N),0,124,1,3
  305. IIDNUM,Insurance Phys ID,0,125,15,3
  306. IDELAY,Insurance Delayed Billing,0,140,1,3
  307. IPRINTID,Insurance Print PIN Number,0,141,1,3
  308. IECS,Insurance EMC Code,0,121,2,3
  309. IECSPAYOR,Ins EMC Payor Number,0,173,5,3
  310. IECSSUBID,Ins EMC Sub-ID,0,178,15,3 
  311. IEXTRA,Ins Extra One,0,193,10,3
  312. IPRNCLAIM,Ins Print Claim Code,0,213,1,3 
  313. IHFIELD,Insured HOH Field,0,234,8,3
  314. IHNEWDATE,Insured HOH New Patient Date,1,177,6,4
  315. IHPATYN,Insured HOH Chart a Patient (Y/N),0,183,1,4
  316. IHCHART,Insured HOH Chart,0,268,8,3
  317. IHNAME,Insured HOH Name,0,10,30,4
  318. IHFIRST,Insured HOH First Name,9,10,30,4
  319. IHMIDDLE,Insured HOH Middle Name,10,10,30,4
  320. IHLAST,Insured HOH Last Name,11,10,30,4
  321. IHSTREET,Insured HOH Street,0,40,30,4
  322. IHCITYLN,Insured HOH Cityline,3,70,32,4
  323. IHCITY,Insured HOH City,0,70,20,4
  324. IHSTATE,Insured HOH State,0,90,2,4
  325. IHZIP,Insured HOH Zip,0,92,10,4
  326. IHPHONE,Insured HOH Phone,2,102,10,4
  327. IHSSN,Insured HOH Soc Sec Num,4,122,10,4
  328. IHBDAY,Insured HOH Birthday,16,222,8,4
  329. IHSEX,Insured HOH Sex,0,221,1,4
  330. IHSIG,Insured HOH Signature (Y/N),0,456,1,4
  331. IHREL,Insured HOH Relation,0,276,1,3
  332. IHPATID,Insured HOH Second ID,0,195,15,4
  333. IHWPHONE,Insured HOH Work Phone,2,957,10,4
  334. IHWPHEXT,Ins. HOH Work Phone Extension,0,967,4,4
  335. IHRETDATE,Insured HOH Emp Retirement Date,1,189,6,4
  336. IEMPLOYER,Insured Employer Code,0,2,5,5
  337. IEFIELD,Insured Employer Field,0,184,5,4
  338. IENAME,Insured Employer Name,0,7,30,5
  339. IESTREET,Insured Employer Street,0,37,30,5
  340. IECITYLN,Insured Employer Cityline,3,67,32,5
  341. IECITY,Insured Employer City,0,67,20,5
  342. IESTATE,Insured Employer State,0,87,2,5
  343. IEZIP,Insured Employer Zip Code,0,89,10,5
  344. IELOC,Insured Employer Location,0,215,6,4
  345. IEPHONE,Insured Employer Phone,2,99,10,5
  346. IEFAXPH,Insured Employer Fax Phone,2,170,10,5
  347. IECONTACT,Insured Employer Contact/ID,0,109,20,5
  348. IEID,Insured Employer ID,0,130,20,5
  349. IETYPE,Insured Employer Address Type,0,129,1,5
  350. OADDRB,Other Ins Address #2,0,234,30,6
  351. ONUM,Other Ins Number,14,277,4,6
  352. OTYPE,Other Ins Type,0,172,1,6
  353. ONAME,Other Ins Name,0,1,30,6
  354. OSTREET,Other Ins Street,0,31,30,6
  355. OCITYLN,Other Ins Cityline,3,61,32,6
  356. OCITY,Other Ins City,0,61,20,6
  357. OSTATE,Other Ins State,0,81,2,6
  358. OZIP,Other Ins Zip,0,83,10,6
  359. OPHONE,Other Ins Phone,2,93,10,6
  360. OFAXPH,Other Ins Fax Phone,2,203,10,6 
  361. OCONTACT,Other Ins Contact,0,103,18,6
  362. OPLAN,Other Ins Plan Name,0,142,30,6
  363. OPOLICY,Other Ins Policy,0,281,20,6
  364. OGROUP,Other Ins Group,0,301,20,6
  365. OCODETYPE,Other Ins Code Type,0,123,1,6
  366. OSIG,Other Ins Signature (Y/N),0,124,1,6
  367. OIDNUM,Other Ins Phys ID,0,125,15,6
  368. OPRINTID,Other Ins Print PIN Number,0,141,1,6
  369. ODELAY,Other Ins Delayed Billing,0,140,1,6
  370. OECS,Other Ins EMC Code,0,121,2,6
  371. OECSPAYOR,Other Ins EMC Payor Number,0,173,5,6
  372. OECSSUBID,Other Ins EMC Sub-ID,0,178,15,6 
  373. OEXTRA,Other Ins Extra One,0,193,10,6
  374. OPRNCLAIM,Other Ins Print Claim Code,0,213,1,6
  375. OHFIELD,Other HOH Field,0,234,8,6
  376. OHNEWDATE,Other HOH New Patient Date,1,177,6,7
  377. OHPATYN,Other HOH Chart a Patient (Y/N),0,183,1,7
  378. OHCHART,Other HOH Chart,0,268,8,6
  379. OHNAME,Other HOH Name,0,10,30,7
  380. OHFIRST,Other HOH First Name,9,10,30,7
  381. OHMIDDLE,Other HOH Middle Name,10,10,30,7
  382. OHLAST,Other HOH Last Name,11,10,30,7
  383. OHSTREET,Other HOH Street,0,40,30,7
  384. OHCITYLN,Other HOH Cityline,3,70,32,7
  385. OHCITY,Other HOH City,0,70,20,7
  386. OHSTATE,Other HOH State,0,90,2,7
  387. OHZIP,Other HOH Zip,0,92,10,7
  388. OHPHONE,Other HOH Phone,2,102,10,7
  389. OHSSN,Other HOH Soc Sec Num,4,122,10,7
  390. OHBDAY,Insured HOH Birthday,16,222,8,7
  391. OHSEX,Insured HOH Sex,0,221,1,7
  392. OHSIG,Other HOH Signature (Y/N),0,456,1,7
  393. OHREL,Other HOH Relation,0,276,1,6
  394. OHPATID,Other HOH Second ID,0,195,15,7
  395. OHWPHONE,Other HOH Work Phone,2,957,10,7
  396. OHWPHEXT,Other HOH Work Phone Extension,0,967,4,7
  397. OHRETDATE,Other HOH Employer Retirement Date,1,189,6,7
  398. OEMPLOYER,Other Employer Code,0,2,5,8
  399. OEFIELD,Other Employer Field,0,184,5,7
  400. OENAME,Other Employer Name,0,7,30,8
  401. OESTREET,Other Employer Street,0,37,30,8
  402. OECITYLN,Other Employer Cityline,3,67,32,8
  403. OECITY,Other Employer City,0,67,20,8
  404. OESTATE,Other Employer State,0,87,2,8
  405. OEZIP,Other Employer Zip Code,0,89,10,8
  406. OELOC,Other Employee Location,0,215,6,7
  407. OEPHONE,Other Employee Phone,2,99,10,8
  408. OEFAXPH,Other Employer Fax Phone,2,170,10,8
  409. OECONTACT,Other Employer Contact/ID,0,109,20,8
  410. OEID,Other Employer ID,0,130,20,8
  411. OETYPE,Other Employer Address Type,0,129,1,8
  412. TADDRB,Tertiary Ins Address #2,0,234,30,17
  413. TNUM,Tertiary Ins Number,14,277,4,17
  414. TTYPE,Tertiary Ins Type,0,172,1,17
  415. TNAME,Tertiary Ins Name,0,1,30,17
  416. TSTREET,Tertiary Ins Street,0,31,30,17
  417. TCITYLN,Tertiary Ins Cityline,3,61,32,17
  418. TCITY,Tertiary Ins City,0,61,20,17
  419. TSTATE,Tertiary Ins State,0,81,2,17
  420. TZIP,Tertiary Ins Zip,0,83,10,17
  421. TPHONE,Tertiary Ins Phone,2,93,10,17
  422. TFAXPH,Tertiary Ins Fax Phone,2,203,10,17
  423. TCONTACT,Tertiary Ins Contact,0,103,18,17
  424. TPLAN,Tertiary Ins Plan Name,0,142,30,17
  425. TPOLICY,Tertiary Ins Policy,0,281,20,17
  426. TGROUP,Tertiary Ins Group,0,301,20,17
  427. TCODETYPE,Tertiary Ins Code Type,0,123,1,17
  428. TSIG,Tertiary Ins Signature (Y/N),0,124,1,17
  429. TIDNUM,Tertiary Ins Phys ID,0,125,15,17
  430. TPRINTID,Tertiary Ins Print PIN Number,0,141,1,17
  431. TDELAY,Tertiary Ins Delayed Billing,0,140,1,17
  432. TECS,Tertiary Ins EMC Code,0,121,2,17
  433. TECSPAYOR,Tertiary Ins EMC Payor Number,0,173,5,17
  434. TECSSUBID,Tertiary Ins EMC Sub-ID,0,178,15,17
  435. TEXTRA,Tertiary Ins Extra One,0,193,10,17
  436. TPRNCLAIM,Tertiary Ins Print Claim Code,0,213,1,17
  437. THFIELD,Tertiary HOH Field,0,234,8,17
  438. THNEWDATE,Tertiary HOH New Patient Date,1,177,6,18
  439. THPATYN,Tertiary HOH Chart a Patient (Y/N),0,183,1,18
  440. THCHART,Tertiary HOH Chart,0,268,8,17
  441. THNAME,Tertiary HOH Name,0,10,30,18
  442. THFIRST,Tertiary HOH First Name,9,10,30,18
  443. THMIDDLE,Tertiary HOH Middle Name,10,10,30,18
  444. THLAST,Tertiary HOH Last Name,11,10,30,18
  445. THSTREET,Tertiary HOH Street,0,40,30,18
  446. THCITYLN,Tertiary HOH Cityline,3,70,32,18
  447. THCITY,Tertiary HOH City,0,70,20,18
  448. THSTATE,Tertiary HOH State,0,90,2,18
  449. THZIP,Tertiary HOH Zip,0,92,10,18
  450. THPHONE,Tertiary HOH Phone,2,102,10,18
  451. THSSN,Tertiary HOH Soc Sec Num,4,122,10,18
  452. THBDAY,Tertiary HOH Birthday,16,222,8,18
  453. THSEX,Tertiary HOH Sex,0,221,1,18
  454. THSIG,Tertiary HOH Signature (Y/N),0,456,1,18
  455. THREL,Tertiary HOH Relation,0,276,1,17
  456. THPATID,Tertiary HOH Second ID,0,195,15,18
  457. THWPHONE,Tertiary HOH Work Phone,2,957,10,18
  458. THWPHEXT,Ter. HOH Work Phone Extension,0,967,4,18
  459. THRETDATE,Tert HOH Employer Retirement Date,1,189,6,18
  460. TEMPLOYER,Tertiary Employer Code,0,2,5,19
  461. TEFIELD,Tertiary Employer Field,0,184,5,18
  462. TENAME,Tertiary Employer Name,0,7,30,19
  463. TESTREET,Tertiary Employer Street,0,37,30,19
  464. TECITYLN,Tertiary Employer Cityline,3,67,32,19
  465. TECITY,Tertiary Employer City,0,67,20,19
  466. TESTATE,Tertiary Employer State,0,87,2,19
  467. TEZIP,Tertiary Employer Zip Code,0,89,10,19
  468. TELOC,Tertiary Employee Location,0,215,6,18
  469. TEPHONE,Tertiary Employee Phone,2,99,10,19
  470. TEFAXPH,Tertiary Employer Fax Phone,2,170,10,19
  471. TECONTACT,Tertiary Employer Contact/ID,0,109,20,19
  472. TEID,Tertiary Employer ID,0,130,20,19
  473. TETYPE,Tertiary Employer Address Type,0,129,1,19
  474. CHNONAVAIL,CHAMPUS Non-availability,0,836,1,2
  475. CHBSERVICE,CHAMPUS Branch of Service,0,837,1,2
  476. CHSPGRADE,CHAMPUS Sponsor Grade,0,838,2,2
  477. CHSPSTATUS,CHAMPUS Sponsor Status,0,840,1,2
  478. CHPROGRAM,CHAMPUS Program for Handicapped,0,841,2,2
  479. CHCEFFECT,CHAMPUS Card Effective Date,1,844,6,2
  480. CHCTERM,CHAMPUS Termination Date,1,850,6,2
  481. 21,10
  482. Form Name,-30,Untitled Form
  483. Form Length,6,66
  484. Form Width,6,79
  485. Left Column Offset,13,0
  486. Laser Printer Download File,14,
  487. Sort Entries By,10,"DATE,DOC"
  488. Summarize Entries By,9,
  489. Separate Forms By,9,
  490. Exclude Form If,7,
  491. Exclude Entry If,8,
  492. Print By Attending Provider,2,N
  493. Pause For Single Sheet Feed,2,N
  494. MEDIGAP Crossover Claims,2,N
  495. Always Accept Assignment,2,N
  496. Print Payments On Forms,2,N
  497. Print Paragraph Diagnosis,2,N
  498. Print Zero Amount Entries,2,N
  499. Use Practice Or Doctor Address,11,D
  500. Print Insurance Address,2,Y
  501. Print Practice/Doctor Address,2,Y
  502. Tax Procedure Code,15,TAX
  503. 18
  504. Date Of Insurances,1,
  505. Range Of Chart Numbers,23,
  506. Range Of Billing Codes,25,
  507. Range Of Indicators,26,
  508. Range Of Primary Insurance,27,
  509. Range Of Secondary Insurance,27,
  510. Range Of Tertiary Insurance,27,
  511. Range Of Providers,24,
  512. Range Of Dates,22,
  513. Range Of Procedure Codes,28,
  514. Range Of Balances,29,
  515. Rebill Insurance Companies,2,N
  516. Range Of Rebill Billing Dates,22,
  517. Custom Data A,-30,
  518. Custom Data B,-30,
  519. Custom Data C,-30,
  520. Custom Data D,-30,
  521. Insurance Types,16,
  522. "Date",6,"Sample Date: Enter |012393 for January 23rd, 1993."
  523. "Yes Or No",1,"Enter |Y for yes or |N for no."
  524. "Yes, No, Or All",1,"Press |[Enter] for all.  Enter |Y for yes or |N for no."
  525. "Print If Balance Older Than",2,"Press |[Enter] for all.  Enter '30' '60' or '90' for 30, 60, or 90 days."
  526. "Billing Mode",1,"Enter |S for standard, |A for anticipated, or |R for remainder billing."
  527. "Length Or Width",3,"Decreasing this number may delete some fields from your format."
  528. "Exclude Patient If",45,"|CHART=ABLEJO10 to exclude patient ABLEJO10. Enter ABLEJO10 within quotes."
  529. "Exclude Transaction If",45,"Sample: enter |TAMT |> |1000 to exclude transactions greater than 1000."
  530. "Code",10,"Example: enter |PHYS for the patients provider."
  531. "Code,Code",30,"Example: enter |DATE,DOC for the entry date and document."
  532. "Practice, Doctor",1,"Enter |P for practice or |D for doctor."
  533. "History Entries After",6,"Enter |010193 to print unpaid history entries after January 1st, 1993."
  534. "Left Column",2,"Example: enter |-2 to adjust form 2 spaces to the left."
  535. "Download",12,"Enter a laser printer form file, or a file containing soft fonts, etc."
  536. "Tax Procedure Code",10,"Example: enter |TAX for the TAX procedure code."
  537. "Insurance Types",9,"Press |[Enter] for all types or |M Medicare |B BC/BS |A Medicaid \|C CHAMPUS |V CHAMPVA |G Group |F FECA |O Other |W Worker's Comp |H HMO |P PPO."
  538. "dates",13,"|050194    053194    May 1, 1994    May 31, 1994"
  539. "chart numbers",17,"|ABLE0010  CLOU6010  ABLE0010       CLOU6010"
  540. "providers",5,"|1         99        1              99"
  541. "billing codes",3,"|B         D         B              D"
  542. "indicators",11,"|IND01     IND20     IND01          IND20"
  543. "insurance companies",9,"|12        99        12             99"
  544. "procedures",21,"|CHECK     VISIT     CHECK          VISIT"
  545. "balances",19,"|30        132.29    30.00          132.29"
  546.