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Text File  |  1995-12-05  |  24KB  |  373 lines
  1. 215
  2. 1,22,8,8,1,2,8,"",1,66,"","216N","Enter the patient's chart number, name or partial name (i.e. JO F).","PACHART"
  3. 1,33,30,30,1,10,30,"",0,4,"","","",""
  4. 5,22,30,30,1,10,30,"Patient Name",5,1059,"","7135C9OT","Enter the patient name.  Name should be: |Last, |First |Middle","PANAME"
  5. 1,33,30,30,1,10,30,"",0,4,"","","",""
  6. 6,22,30,30,1,40,30,"",0,1056,"","7135C9OT","Enter the patient's street address.","STREET"
  7. 7,22,20,20,1,70,20,"",30,1056,"","7135C9OT","Enter the patient's city.","CITY"
  8. 8,22,2,2,1,90,2,"",14,32,"","7135C9OT","Enter the patient's state.","STATE"
  9. 9,19,2,5,1,92,10,"",0,16,"","","",""
  10. 9,22,10,10,19,2,5,"",7,33,"","71356C89T","Enter the patient's zip code.","ZIP"
  11. 9,19,2,5,1,92,10,"",0,16,"","","",""
  12. 10,22,10,10,1,882,10,"",14,32,"","7135C9OT","Enter the patient's country.","COUNTRY"
  13. 11,22,10,14,1,102,10,"",16,32,"","7135C9OT","Enter the patient's phone number, (don't include punctuation).","PHONE"
  14. 12,22,10,14,1,112,10,"",16,32,"","7135C9OT","Enter the patient's 2nd phone number, (don't include punctuation).","PHONE"
  15. 13,22,8,10,1,222,8,"Patient's Birthdate",11,96,"","7135C9OT","Enter the patient's date of birth.  Format: |MMDDYY or |MMDDYYYY","BDATE"
  16. 8,64,1,6,1,221,1,"",13,97,"MF-Male;Female;","7135C9OT","Enter |M for |male, |F for |female.","SEX"
  17. 9,64,1,9,1,447,1,"Marital Status",13,32,"SMXDWU-Single;Married;Separated;Divorced;Widowed;Unknown;","7135C9OT","|S Single |M Married |X Separated |D Divorced |W Widow |U Unknown","MARITAL"
  18. 10,64,10,12,1,122,10,"",29,96,"","7135C9OT","Enter the patient's social security number (Don't use puncuation).","SSNO"
  19. 11,64,1,11,1,449,1,"",13,32,"FPNU-Full Time;Part Time;Non-Student;Unknown;","7135C9OT","Enter |F Full time  |P Part time  |N Non-student  |U Unknown","STUSTAT"
  20. 12,64,15,15,1,195,15,"",14,32,"","216","Enter another ID to use when searching for this patient (optional).","PATID2"
  21. 13,64,1,3,1,183,1,"",13,32,"YN-Yes;No;","7135C9OT","Enter |Y for yes, this person is a patient, |N for no, they are not a patient.","ISPATIENT"
  22. 14,64,1,3,1,456,1,"",13,33,"YN-Yes;No;","7135C9OT","Enter |Y for `signature on file' or |N for no.","SIGNATURE"
  23. 15,29,30,30,9,7,30,"",0,4,"","","",""
  24. 15,9,2,5,1,184,5,"",0,16,"","","",""
  25. 15,22,5,5,9,2,5,"",7,97,"","71356C89T","Enter the employer address code or use F6 to search by name.","EMPLOYER"
  26. 15,9,2,5,1,184,5,"",0,16,"","","",""
  27. 15,29,30,30,9,7,30,"",0,4,"","","",""
  28. 16,22,6,6,1,215,6,"",0,32,"","7135C9OT","Enter employer location.","EMPLOC"
  29. 17,22,1,12,1,448,1,"",13,32,"FPRNU-Full Time;Part Time;Retired;Not Employed;Unknown;","7135C9OT","Enter |F Full time  |P Part time  |R Retired  |N Not employed  |U Unknown","EMPSTAT"
  30. 18,22,6,8,1,189,6,"",11,96,"","7135C9OT","Enter the employment retirement date (if any).","EMPDATE"
  31. 19,22,10,14,1,957,10,"",16,32,"","7135C9OT","Enter the work phone number, (don't include punctuation).","EMPPHONE"
  32. 20,22,4,4,1,967,4,"",0,32,"","7135C9OT","Enter the work phone extension (if any).","EMPPHONE"
  33. 23,22,8,8,1,2,8,"",0,4,"","","",""
  34. 23,33,30,30,1,10,30,"",0,4,"","","",""
  35. 28,2,2,8,1,132,8,"",0,16,"","","",""
  36. 28,36,30,30,2,10,30,"",0,4,"","","",""
  37. 28,26,8,8,2,2,8,"",2,97,"","1356C89OT","Enter the insured's chart number or partial name (i.e. JO F).","INSCHART"
  38. 28,36,30,30,2,10,30,"",0,4,"","","",""
  39. 28,2,2,8,1,132,8,"",0,16,"","","",""
  40. 29,36,30,30,5,1,30,"",0,4,"","","",""
  41. 29,5,0,0,1,159,4,"",0,16,"","","",""
  42. 29,26,4,4,5,0,4,"Primary Carrier Number",4,96,"","1356C89OT","Enter the primary insurance company number.","INSNAME"
  43. 29,5,0,0,1,159,4,"",0,16,"","","",""
  44. 29,36,30,30,5,1,30,"",0,4,"","","",""
  45. 30,26,20,20,1,269,20,"",14,32,"","7135C9OT","Enter the insured's policy number.","POLICY"
  46. 31,26,20,20,1,289,20,"",14,32,"","7135C9OT","Enter the insured's group number.","GROUP"
  47. 32,26,1,6,1,140,1,"Relationship to Insured",13,32,"1234-Self;Spouse;Child;Other;","7135C9OT","Enter |1 for self, |2 for spouse, |3 for child or |4 for other.","RELINS"
  48. 33,26,1,3,1,266,1,"",13,32,"YN-Yes;No;","7135C9OT","Enter |Y to accept assignment of benefits or |N for no.","ACCASSIGN"
  49. 34,26,7,7,1,774,7,"",19,32,"","7135C9OT","Enter this policy's co-payment amount (if any).","COPAY"
  50. 35,26,1,3,1,171,1,"",13,32,"YN-Yes;No;","7135C9OT","Enter |Y for yes, if this policy is capitated or |N for no.","CAPITATED"
  51. 38,15,3,3,1,309,3,"",31,97,"","7135C9OT","Enter the percent of coverage A","COVERAGE"
  52. 39,15,3,3,1,485,3,"",31,96,"","7135C9OT","Enter the percent of coverage B","COVERAGE"
  53. 40,15,3,3,1,491,3,"",31,96,"","7135C9OT","Enter the percent of coverage C","COVERAGE"
  54. 41,15,3,3,1,497,3,"",31,96,"","7135C9OT","Enter the percent of coverage D","COVERAGE"
  55. 38,31,3,3,1,503,3,"",31,96,"","7135C9OT","Enter the percent of coverage E","COVERAGE"
  56. 39,31,3,3,1,509,3,"",31,96,"","7135C9OT","Enter the percent of coverage F","COVERAGE"
  57. 40,31,3,3,1,515,3,"",31,96,"","7135C9OT","Enter the percent of coverage G","COVERAGE"
  58. 41,31,3,3,1,521,3,"",31,96,"","7135C9OT","Enter the percent of coverage H","COVERAGE"
  59. 37,66,1,13,1,836,1,"",13,33,"YNZ-NA Obtained;NA Not neces.;Other Pd 75%;","7135C9OT","|Y Non-avail statement obtained.  |N Non-avail statement not necessary. |Z Other carrier has paid at least 75%.","CHANAI"
  60. 38,66,1,13,1,837,1,"",13,32,"12345678-Army;Air Force;Marines;Navy;Coast Guard;Pub Health;NOAA;Champ VA;","7135C9OT","|1 Army |2 Air Force |3 Marines |4 Navy |5 Coast Guard |6 Public Health |7 NOAA |8 Champs VA","CHABRANCH"
  61. 39,66,2,2,1,838,2,"",14,32,"","7135C9OT","Enter the sponsor grade: |W1-W4, |E1-E4, |G1, |S1, |VA, |01-11, |19, |41-58, |90 =Unknown, |99 =Other","CHAGRADE"
  62. 40,66,1,8,1,840,1,"",13,32,"ABCDFHIJKNORTVXZ-Active;Recalled;Civilian;Deceased;Former Member;Medal Honor;Perm Dis;Acadamy;100% Dis;Nat. Guard;Temp Dis;Retired;Foreign Mil;Reserves;Other;Unknown;","7135C9OT","Enter |A Active, |C Civilian, |D Deceased, |R Retired. \Press |F1 Help for additional choices.","CHASTAT"
  63. 41,66,2,2,1,841,2,"",14,32,"","7135C9OT","Enter code |A, |B, |D or |C1-C9 (or blank)","CHAHANDI"
  64. 42,66,6,8,1,844,6,"",11,96,"","7135C9OT","Enter the date in |MMDDYY format.","CHADATE"
  65. 43,66,6,8,1,850,6,"",11,96,"","7135C9OT","Enter the date in |MMDDYY format.","CHADATE"
  66. 45,22,8,8,1,2,8,"",0,4,"","","",""
  67. 45,33,30,30,1,10,30,"",0,4,"","","",""
  68. 50,3,2,8,1,141,8,"",0,16,"","","",""
  69. 50,36,30,30,3,10,30,"",0,4,"","","",""
  70. 50,26,8,8,3,2,8,"",2,97,"","1356C89OT","Enter the insured's chart number or partial name (i.e. JO F).","INSCHART"
  71. 50,36,30,30,3,10,30,"",0,4,"","","",""
  72. 50,3,2,8,1,141,8,"",0,16,"","","",""
  73. 51,36,30,30,6,1,30,"",0,4,"","","",""
  74. 51,6,0,0,1,163,4,"",0,16,"","","",""
  75. 51,26,4,4,6,0,4,"Secondary Carrier Number",4,96,"","1356C89OT","Enter the secondary insurance company number.","INSNAME"
  76. 51,6,0,0,1,163,4,"",0,16,"","","",""
  77. 51,36,30,30,6,1,30,"",0,4,"","","",""
  78. 52,26,20,20,1,315,20,"",14,32,"","7135C9OT","Enter the insured's policy number.","POLICY"
  79. 53,26,20,20,1,576,20,"",14,32,"","7135C9OT","Enter the insured's group number.","GROUP"
  80. 54,26,1,6,1,149,1,"Relationship to Insured",13,32,"1234-Self;Spouse;Child;Other;","7135C9OT","Enter |1 for self, |2 for spouse, |3 for child or |4 for other.","RELINS"
  81. 55,26,1,3,1,267,1,"",13,32,"YN-Yes;No;","7135C9OT","Enter |Y to accept assignment of benefits or |N for no.","ACCASSIGN"
  82. 60,30,3,3,1,335,3,"",31,97,"","7135C9OT","Enter the percent of coverage A","COVERAGE"
  83. 61,30,3,3,1,488,3,"",31,96,"","7135C9OT","Enter the percent of coverage B","COVERAGE"
  84. 62,30,3,3,1,494,3,"",31,96,"","7135C9OT","Enter the percent of coverage C","COVERAGE"
  85. 63,30,3,3,1,500,3,"",31,96,"","7135C9OT","Enter the percent of coverage D","COVERAGE"
  86. 60,59,3,3,1,506,3,"",31,96,"","7135C9OT","Enter the percent of coverage E","COVERAGE"
  87. 61,59,3,3,1,512,3,"",31,96,"","7135C9OT","Enter the percent of coverage F","COVERAGE"
  88. 62,59,3,3,1,518,3,"",31,96,"","7135C9OT","Enter the percent of coverage G","COVERAGE"
  89. 63,59,3,3,1,524,3,"",31,96,"","7135C9OT","Enter the percent of coverage H","COVERAGE"
  90. 67,22,8,8,1,2,8,"",0,4,"","","",""
  91. 67,33,30,30,1,10,30,"",0,4,"","","",""
  92. 72,4,2,8,1,150,8,"",0,16,"","","",""
  93. 72,36,30,30,4,10,30,"",0,4,"","","",""
  94. 72,26,8,8,4,2,8,"",2,97,"","1356C89OT","Enter the insured's chart number or partial name (i.e. JO F).","INSCHART"
  95. 72,36,30,30,4,10,30,"",0,4,"","","",""
  96. 72,4,2,8,1,150,8,"",0,16,"","","",""
  97. 73,36,30,30,7,1,30,"",0,4,"","","",""
  98. 73,7,0,0,1,167,4,"",0,16,"","","",""
  99. 73,26,4,4,7,0,4,"Tertiary Carrier Number",4,96,"","1356C89OT","Enter the tertiary insurance company number.","INSNAME"
  100. 73,7,0,0,1,167,4,"",0,16,"","","",""
  101. 73,36,30,30,7,1,30,"",0,4,"","","",""
  102. 74,26,20,20,1,710,20,"",14,32,"","7135C9OT","Enter the insured's policy number.","POLICY"
  103. 75,26,20,20,1,730,20,"",14,32,"","7135C9OT","Enter the insured's group number.","GROUP"
  104. 76,26,1,6,1,158,1,"Relationship to Insured",13,32,"1234-Self;Spouse;Child;Other;","7135C9OT","Enter |1 for self, |2 for spouse, |3 for child or |4 for other.","RELINS"
  105. 77,26,1,3,1,268,1,"",13,32,"YN-Yes;No;","7135C9OT","Enter |Y to accept assignment of benefits or |N for no.","ACCASSIGN"
  106. 82,30,3,3,1,750,3,"",31,97,"","7135C9OT","Enter the percent of coverage A","COVERAGE"
  107. 83,30,3,3,1,753,3,"",31,96,"","7135C9OT","Enter the percent of coverage B","COVERAGE"
  108. 84,30,3,3,1,756,3,"",31,96,"","7135C9OT","Enter the percent of coverage C","COVERAGE"
  109. 85,30,3,3,1,759,3,"",31,96,"","7135C9OT","Enter the percent of coverage D","COVERAGE"
  110. 82,59,3,3,1,762,3,"",31,96,"","7135C9OT","Enter the percent of coverage E","COVERAGE"
  111. 83,59,3,3,1,765,3,"",31,96,"","7135C9OT","Enter the percent of coverage F","COVERAGE"
  112. 84,59,3,3,1,768,3,"",31,96,"","7135C9OT","Enter the percent of coverage G","COVERAGE"
  113. 85,59,3,3,1,771,3,"",31,96,"","7135C9OT","Enter the percent of coverage H","COVERAGE"
  114. 89,22,8,8,1,2,8,"",0,4,"","","",""
  115. 89,33,30,30,1,10,30,"",0,4,"","","",""
  116. 93,28,1,3,1,345,1,"",13,33,"YN-Yes;No;","7135C9OT","Enter |Y for |yes or |N for |no.","EMPREL"
  117. 94,28,1,4,1,346,1,"",13,32,"YNA-Yes;No;Auto;","7135C9OT","Enter |Y for |yes, |N for |no, or |A for |auto |accident","ACCREL"
  118. 95,28,2,2,1,596,2,"",14,32,"","7135C9OT","Enter the two letter postal state code.","ACCSTATE"
  119. 96,28,1,3,1,348,1,"",13,32,"YN-Yes;No;","7135C9OT","Enter |Y for |yes or |N for |no.","EMGREL"
  120. 97,28,6,8,1,359,6,"",18,96,"","7135C9OT","Enter the date in |MMDDYY format or |G for |Gradual, |N for |N/A.","NGDATE"
  121. 98,28,1,7,1,451,1,"",13,64,"IL-Illness;LMP;","7135C9OT","Enter |I for |illness, |L for |LMP (for electronic claims only).","FSIND"
  122. 99,28,6,8,1,598,6,"",18,96,"","7135C9OT","Enter the date in |MMDDYY format or |G for |Gradual, |N for |N/A.","NGDATE"
  123. 100,28,1,3,1,347,1,"Similar Symptom Indicator",13,64,"YN-Yes;No;","7135C9OT","Enter |Y for |yes or |N for |no (for electronic claims only).","SSIND"
  124. 101,28,6,8,1,365,6,"",11,96,"","7135C9OT","Enter the date first consulted for this illness.  Format: |MMDDYY","DATE"
  125. 102,28,6,8,1,604,6,"",18,96,"","7135C9OT","Enter the date in |MMDDYY format or |G for |Gradual, |N for |N/A.","NGDATE"
  126. 102,40,6,8,1,371,6,"",18,64,"","7135C9OT","Enter the date in |MMDDYY format or |G for |Gradual, |N for |N/A.","NGDATE"
  127. 103,28,6,8,1,377,6,"",18,96,"","7135C9OT","Enter the date in |MMDDYY format or |G for |Gradual, |N for |N/A.","NGDATE"
  128. 103,40,6,8,1,383,6,"",18,64,"","7135C9OT","Enter the date in |MMDDYY format or |G for |Gradual, |N for |N/A.","NGDATE"
  129. 104,28,6,8,1,389,6,"",18,96,"","7135C9OT","Enter the date in |MMDDYY format or |G for |Gradual, |N for |N/A.","NGDATE"
  130. 104,40,6,8,1,395,6,"",18,64,"","7135C9OT","Enter the date in |MMDDYY format or |G for |Gradual, |N for |N/A.","NGDATE"
  131. 105,28,6,8,1,401,6,"",18,96,"","7135C9OT","Enter the date in |MMDDYY format or |G for |Gradual, |N for |N/A.","NGDATE"
  132. 105,40,6,8,1,407,6,"",18,64,"","7135C9OT","Enter the date in |MMDDYY format or |G for |Gradual, |N for |N/A.","NGDATE"
  133. 106,28,6,8,1,951,6,"",11,96,"","7135C9OT","Enter the date in |MMDDYY format.","DATE"
  134. 107,35,30,30,12,7,30,"",0,4,"","","",""
  135. 107,12,2,5,1,339,5,"",0,16,"","","",""
  136. 107,28,5,5,12,2,5,"",7,96,"","1356C89OT","Enter the address code of the facility where services were rendered.","FACNAME"
  137. 107,12,2,5,1,339,5,"",0,16,"","","",""
  138. 107,35,30,30,12,7,30,"",0,4,"","","",""
  139. 108,28,20,20,1,640,20,"",0,32,"","7135C9OT","Check with the insurance carrier for what to put here.","LOCAL"
  140. 109,28,50,50,1,660,50,"",0,32,"","7135C9OT","Check with the insurance carrier for what to put here.","LOCAL"
  141. 93,61,1,18,1,428,1,"",13,33,"123456-Injured/Home;Injured/School;Injured/Recreation;Work/Self Emp.;Work/Non Collision;Motorcycle;","7135C9OT","|1 Injured/Home  |2 Injured/School  |3 Injured/During Recreation  |4 Work Injury/Self Employed  |5 Work Injury/Non Collision  |6 Motorcycle Injury","NATACC"
  142. 94,61,1,3,1,349,1,"",13,32,"YN-Yes;No;","7135C9OT","Enter |Y for |yes or |N for |no.","MEDICAID"
  143. 95,61,1,3,1,350,1,"",13,32,"YN-Yes;No;","7135C9OT","Enter |Y for |yes or |N for |no.","MEDICAID"
  144. 96,61,12,12,1,610,12,"",0,96,"","7135C9OT","Enter the Medicaid resubmission code.","MEDICAID"
  145. 97,61,18,18,1,622,18,"",0,64,"","7135C9OT","Enter the Medicaid original reference number.","MEDICAID"
  146. 98,61,15,15,1,413,15,"",0,96,"","7135C9OT","Enter the prior authorization number.","MEDICAID"
  147. 99,61,1,1,1,450,1,"",0,32,"","7135C9OT","Enter the level of disability based on Karnofsky Performance Status Scale.  Press |F1 more information.","DEATHID"
  148. 100,61,1,3,1,351,1,"",13,32,"YN-Yes;No;","7135C9OT"","Enter |Y for |yes or |N for |no.","LAB"
  149. 101,61,7,7,1,352,7,"",19,96,"","7135C9OT","Enter the amount of the lab charges.","LAB"
  150. 103,76,1,3,1,892,1,"",13,97,"LNC-Lim;Nor;Con;","7135C9OT","Enter |L for |limited, |N for |normal, or |C for |conditional","WORKMAN"
  151. 104,76,3,3,1,893,3,"",31,32,"","7135C9OT","Enter the percent of permanent disability, (i.e. |30 for 30%).","WORKMAN"
  152. 111,22,8,8,1,2,8,"",0,4,"","","",""
  153. 111,33,30,30,1,10,30,"",0,4,"","","",""
  154. 117,36,44,44,14,12,44,"",0,4,"","","",""
  155. 117,14,2,10,1,896,10,"",0,16,"","","",""
  156. 117,25,10,10,14,2,10,"",10,97,"","1356C89OT","Enter the first diagnosis code.","DIAG"
  157. 117,14,2,10,1,896,10,"",0,16,"","","",""
  158. 117,36,44,44,14,12,44,"",0,4,"","","",""
  159. 118,36,44,44,15,12,44,"",0,4,"","","",""
  160. 118,15,2,10,1,906,10,"",0,16,"","","",""
  161. 118,25,10,10,15,2,10,"",10,96,"","1356C89OT","Enter the second diagnosis code.","DIAG"
  162. 118,15,2,10,1,906,10,"",0,16,"","","",""
  163. 118,36,44,44,15,12,44,"",0,4,"","","",""
  164. 119,36,44,44,16,12,44,"",0,4,"","","",""
  165. 119,16,2,10,1,916,10,"",0,16,"","","",""
  166. 119,25,10,10,16,2,10,"",10,96,"","1356C89OT","Enter the third diagnosis code.","DIAG"
  167. 119,16,2,10,1,916,10,"",0,16,"","","",""
  168. 119,36,44,44,16,12,44,"",0,4,"","","",""
  169. 120,36,44,44,17,12,44,"",0,4,"","","",""
  170. 120,17,2,10,1,926,10,"",0,16,"","","",""
  171. 120,25,10,10,17,2,10,"",10,96,"","1356C89OT","Enter the fourth diagnosis code.","DIAG"
  172. 120,17,2,10,1,926,10,"",0,16,"","","",""
  173. 120,36,44,44,17,12,44,"",0,4,"","","",""
  174. 122,25,47,47,1,529,47,"",0,33,"","7135C9OT","Enter notes or comments.","ALLNOTES"
  175. 123,25,15,15,1,936,15,"",14,32,"","7135C9OT","Enter extra diagnosis description or level of subluxation (i.e. C1C2T3).","EXTDIAG"
  176. 133,22,8,8,1,2,8,"",0,4,"","","",""
  177. 133,33,30,30,1,10,30,"",0,4,"","","",""
  178. 138,29,30,30,21,4,30,"",0,4,"","","",""
  179. 138,21,3,1,1,238,1,"",0,16,"","","",""
  180. 138,25,1,1,21,3,1,"",33,96,"","71356C89T","Enter any letter from |A to |Z or number from |0 to |9.","BILLCODE"
  181. 138,21,3,1,1,238,1,"",0,16,"","","",""
  182. 138,29,30,30,21,4,30,"",0,4,"","","",""
  183. 140,25,4,4,1,452,4,"",14,32,"","135C9OT","Enter a value to indicate that other arrangements for this \account have been made.","PATARR"
  184. 141,25,5,5,1,239,5,"",14,32,"","7135C9OT","Enter any value. Use to indicate patient groups.","PATIND"
  185. 142,25,1,3,1,344,1,"",13,32,"YN-Yes;No;","7135C9OT"","Enter |Y for |yes or |N for |no, to stop this patient from getting a patient statement. (Chart numbers ending in zero only.)","PATSTMNT"
  186. 143,25,1,1,1,338,1,"",13,96,"ABCDEFGHIJKLMNOPQRSTUVWXYZ-","7135C9OT","Enter any letter from |A to |Z.","PRICECODE"
  187. 146,36,1,30,8,1,30,"",0,4,"","","",""
  188. 146,8,0,0,1,244,2,"",0,16,"","","",""
  189. 146,25,2,2,8,0,2,"",6,225,"","1356C89OT","Enter the assigned provider number.","ASSPROV"
  190. 146,8,0,0,1,244,2,"",0,16,"","","",""
  191. 146,36,1,30,8,1,30,"",0,4,"","","",""
  192. 147,38,30,30,10,7,30,"",0,4,"","","",""
  193. 147,10,2,5,1,210,5,"",0,16,"","","",""
  194. 147,25,5,5,10,2,5,"",7,96,"","1356C89OT","Enter the address code for the referring physician.","REFPHY"
  195. 147,10,2,5,1,210,5,"",0,16,"","","",""
  196. 147,38,30,30,10,7,30,"",0,4,"","","",""
  197. 148,38,30,30,13,7,30,"",0,4,"","","",""
  198. 148,13,2,5,1,429,5,"",0,16,"","","",""
  199. 148,25,5,5,13,2,5,"",7,96,"","1356C89OT","Enter the address code for the referral source. (if any)","REFNAME"
  200. 148,13,2,5,1,429,5,"",0,16,"","","",""
  201. 148,38,30,30,13,7,30,"",0,4,"","","",""
  202. 149,38,30,30,11,7,30,"",0,4,"","","",""
  203. 149,11,2,5,1,172,5,"",0,16,"","","",""
  204. 149,25,5,5,11,2,5,"",7,96,"","1356C89OT","Enter the address code for the attorney (if any).","ATTNAME"
  205. 149,11,2,5,1,172,5,"",0,16,"","","",""
  206. 149,38,30,30,11,7,30,"",0,4,"","","",""
  207. 151,25,20,37,1,811,20,"",12,97,"","7135C9OT","Enter the credit card number.","CCARD"
  208. 152,25,4,4,1,831,4,"",15,64,"","7135C9OT","Enter the credit card expiration date.","CCARD"
  209. 153,25,30,30,1,781,30,"",0,64,"","7135C9OT","Enter the name on the credit card.","CCARD"
  210. 140,63,15,15,1,866,15,"",0,33,"","7135C9OT","Enter the authorization number for the current visit series (if any).","VISIT"
  211. 141,63,1,1,1,881,1,"",13,96,"ABCDEFGHIJKLMNOPQRSTUVWXYZ-","7135C9OT","Enter any letter from |A to |Z.","VISIT"
  212. 142,63,2,2,1,864,2,"",20,32,"","7135C9OT","Enter the total number of visits allowed.","VISIT"
  213. 143,63,2,2,1,862,2,"",20,32,"","7135C9OT","Enter the current visit number. This number is maintained by the program.","VISIT"
  214. 144,63,6,8,1,856,6,"",11,64,"","7135C9OT","This date is maintained by the program. Edit this only to make corrections.","VISIT"
  215. 155,22,8,8,1,2,8,"",0,4,"","","",""
  216. 155,33,30,30,1,10,30,"",0,4,"","","",""
  217. 155
  218.       Chart Number:
  219. ╔════════╗┌────────┐┌────────┐┌────────┐┌─────────┐┌─────────┐┌───────┐┌─────┐
  220. ║Personal║│Policy 1││Policy 2││Policy 3││Condition││Diagnoses││Account││Other│
  221. ╜        ╙┴────────┴┴────────┴┴────────┴┴─────────┴┴─────────┴┴───────┴┴─────┴
  222.       Patient Name:
  223.             Street:
  224.               City:
  225.              State:                                Sex (M/F):
  226.           Zip Code:                           Marital Status:
  227.            Country:                   Social Security Number:
  228.              Phone:                           Student Status:
  229.           Phone #2:                            Patient ID #2:
  230.         Birth Date:                               Is Patient:
  231.                                            Signature on File:
  232.           Employer:
  233.           Location:
  234.  Employment Status:
  235.    Retirement Date:
  236.         Work Phone:
  237.    Phone Extension:
  238.  
  239.  
  240.       Chart Number:
  241. ┌────────┐╔════════╗┌────────┐┌────────┐┌─────────┐┌─────────┐┌───────┐┌─────┐
  242. │Personal│║Policy 1║│Policy 2││Policy 3││Condition││Diagnoses││Account││Other│
  243. ┴────────┴╜        ╙┴────────┴┴────────┴┴─────────┴┴─────────┴┴───────┴┴─────┴
  244.  
  245.        Primary Insured:
  246.      Insurance Company:
  247.          Policy Number:
  248.           Group Number:
  249.           Relationship:
  250.      Accept Assignment:
  251.             Co-payment:
  252.         Capitated Plan:
  253. ─── Coverage by Service Class ───┬───────────────── CHAMPUS ──────────────────
  254.                                  │  Non-availability Indicator:
  255.   Class A %:      Class E %:     │           Branch of Service:
  256.   Class B %:      Class F %:     │               Sponsor Grade:
  257.   Class C %:      Class G %:     │              Sponsor Status:
  258.   Class D %:      Class H %:     │   Special Program Indicator:
  259.                                  │         Card Effective Date:
  260.                                  │            Termination Date:
  261.                                  │
  262.       Chart Number:
  263. ┌────────┐┌────────┐╔════════╗┌────────┐┌─────────┐┌─────────┐┌───────┐┌─────┐
  264. │Personal││Policy 1│║Policy 2║│Policy 3││Condition││Diagnoses││Account││Other│
  265. ┴────────┴┴────────┴╜        ╙┴────────┴┴─────────┴┴─────────┴┴───────┴┴─────┴
  266.  
  267.      Secondary Insured:
  268.      Insurance Company:
  269.          Policy Number:
  270.           Group Number:
  271.           Relationship:
  272.      Accept Assignment:
  273.  
  274.  
  275. ──────────────── Insurance Coverage by Service Classification ────────────────
  276.  
  277.                  Class A %:                   Class E %:                      
  278.                  Class B %:                   Class F %:                      
  279.                  Class C %:                   Class G %:                      
  280.                  Class D %:                   Class H %:                      
  281.  
  282.  
  283.  
  284.       Chart Number:
  285. ┌────────┐┌────────┐┌────────┐╔════════╗┌─────────┐┌─────────┐┌───────┐┌─────┐
  286. │Personal││Policy 1││Policy 2│║Policy 3║│Condition││Diagnoses││Account││Other│
  287. ┴────────┴┴────────┴┴────────┴╜        ╙┴─────────┴┴─────────┴┴───────┴┴─────┴
  288.  
  289.       Tertiary Insured:
  290.      Insurance Company:
  291.          Policy Number:
  292.           Group Number:
  293.           Relationship:
  294.      Accept Assignment:
  295.  
  296.  
  297. ──────────────── Insurance Coverage by Service Classification ────────────────
  298.  
  299.                  Class A %:                   Class E %:
  300.                  Class B %:                   Class F %:
  301.                  Class C %:                   Class G %:
  302.                  Class D %:                   Class H %:
  303.  
  304.  
  305.  
  306.       Chart Number:
  307. ┌────────┐┌────────┐┌────────┐┌────────┐╔═════════╗┌─────────┐┌───────┐┌─────┐
  308. │Personal││Policy 1││Policy 2││Policy 3│║Condition║│Diagnoses││Account││Other│
  309. ┴────────┴┴────────┴┴────────┴┴────────┴╜         ╙┴─────────┴┴───────┴┴─────┴
  310.       Employment Related:              Nature of Accident:
  311.         Accident Related:                           EPSDT:
  312.           Accident State:                 Family Planning:
  313.                Emergency:         Medicaid Resubmission #:
  314.  Injury/Illness/LMP Date:              Original Reference:
  315.        Illness Indicator:           Prior Authorization #:
  316.    Date Similar Symptoms:                    Death/Status:
  317.    Same/Similar Symptoms:                Outside Lab Work:
  318.  First Consultation Date:                     Lab Charges:
  319.         Date Unable Work:          to           
  320.         Total Disability:          to           Return to Work Indicator:
  321.       Partial Disability:          to             Permanent Disability %:
  322.          Hospitalization:          to
  323.       Date of Last X-Ray:
  324.                 Facility:
  325.            Local Use (A):
  326.            Local Use (B):
  327.  
  328.       Chart Number:
  329. ┌────────┐┌────────┐┌────────┐┌────────┐┌─────────┐╔═════════╗┌───────┐┌─────┐
  330. │Personal││Policy 1││Policy 2││Policy 3││Condition│║Diagnoses║│Account││Other│
  331. ┴────────┴┴────────┴┴────────┴┴────────┴┴─────────┴╜         ╙┴───────┴┴─────┴
  332.  
  333.  
  334.  Default Diagnosis #1:
  335.  Default Diagnosis #2:
  336.  Default Diagnosis #3:
  337.  Default Diagnosis #4:
  338.  
  339.       Allergies/Notes:
  340.  Level of Subluxation:
  341.  
  342.  
  343.  
  344.  
  345.  
  346.  
  347.  
  348.  
  349.  
  350.       Chart Number:
  351. ┌────────┐┌────────┐┌────────┐┌────────┐┌─────────┐┌─────────┐╔═══════╗┌─────┐
  352. │Personal││Policy 1││Policy 2││Policy 3││Condition││Diagnoses│║Account║│Other│
  353. ┴────────┴┴────────┴┴────────┴┴────────┴┴─────────┴┴─────────┴╜       ╙┴─────┴
  354.  
  355.          Billing Code: 
  356.  
  357.    Other Arrangements:           Visit Series Authorization:
  358.     Patient Indicator:                      Visit Series ID:
  359.       Print Statement:          Authorized Number of Visits:  
  360.            Price Code:                 Current Visit Number:
  361.                                             Last Visit Date:
  362.  
  363.     Assigned Provider:
  364.    Referring Provider:
  365.       Referral Source:
  366.              Attorney:
  367.  
  368.    Credit Card Number:
  369.  Card Expiration Date:
  370.      Credit Card Name:
  371.  
  372.       Chart Number:
  373.