| *AMOUNT OF MILITARY RETIREMENT |
{{ pat.amountOfMilitaryRetirement }} |
| *AMOUNT OF SOCIAL SECURITY |
{{ pat.amountOfSocialSecurity }} |
| *CATEGORY OF BENEFICIARY |
{{ pat.categoryOfBeneficiary }} |
| *CLAIM FOLDER LOCATION |
{{ pat.claimFolderLocation }} |
| *CURRENT PC PRACTITIONER |
{{ pat.currentPcPractitioner }} |
| *CURRENT PC TEAM |
{{ pat.currentPcTeam }} |
| *HEIGHT(cm) |
{{ pat.heightCm }} |
| *REACTIONS |
{{ pat.reactions }} |
| *WEIGHT(kg) |
{{ pat.weightKg }} |
| 1U4N |
{{ pat.oneU4n }} |
| 2ND MOST RECENT DATE OF CARE |
{{ pat.secondMostRecentDateOfCare }} |
| 2ND MOST RECENT LOCATION |
{{ pat.secondMostRecentLocation }} |
| ABSENCE DIVISION |
{{ pat.absenceDivision }} |
| ADDRESS CHANGE DT/TM |
{{ pat.addressChangeDttm }} |
| ADDRESS CHANGE SITE |
{{ pat.addressChangeSite }} |
| ADDRESS CHANGE SOURCE |
{{ pat.addressChangeSource }} |
| ADDRESS CHANGE USER |
{{ pat.addressChangeUser }} |
| AGE |
{{ pat.age }} |
| AGENCY/ALLIED COUNTRY |
{{ pat.agencyAlliedCountry }} |
| AGENT ORANGE EXAM DATE |
{{ pat.agentOrangeExamDate }} |
| AGENT ORANGE EXPOS. INDICATED? |
{{ pat.agentOrangeExposIndicated }} |
| AGENT ORANGE EXPOSURE LOCATION |
{{ pat.agentOrangeExposureLocation }} |
| AGENT ORANGE REGISTRATION # |
{{ pat.agentOrangeRegistrationNo }} |
| AGENT ORANGE REGISTRATION DATE |
{{ pat.agentOrangeRegistrationDate }} |
| AGENT ORANGE REPORTED TO C.O. |
{{ pat.agentOrangeReportedToCO }} |
| AMOUNT OF AID & ATTENDANCE |
{{ pat.amountOfAidAttendance }} |
| AMOUNT OF GI INSURANCE |
{{ pat.amountOfGiInsurance }} |
| AMOUNT OF HOUSEBOUND |
{{ pat.amountOfHousebound }} |
| AMOUNT OF OTHER INCOME |
{{ pat.amountOfOtherIncome }} |
| AMOUNT OF OTHER RETIREMENT |
{{ pat.amountOfOtherRetirement }} |
| AMOUNT OF SSI |
{{ pat.amountOfSsi }} |
| AMOUNT OF VA DISABILITY |
{{ pat.amountOfVaDisability }} |
| AMOUNT OF VA PENSION |
{{ pat.amountOfVaPension }} |
| APPOINTMENT REQUEST COMMENT |
{{ pat.appointmentRequestComment }} |
| APPOINTMENT REQUEST DATE |
{{ pat.appointmentRequestDate }} |
| APPOINTMENT REQUEST ON 1010EZ |
{{ pat.appointmentRequestOn_1010ez }} |
| APPOINTMENT REQUEST STATUS |
{{ pat.appointmentRequestStatus }} |
| ATTENDING PHYSICIAN |
{{ pat.attendingPhysician }} |
| BAD ADDRESS INDICATOR |
{{ pat.badAddressIndicator }} |
| CAMP LEJEUNE |
{{ pat.campLejeune }} |
| CAMP LEJEUNE CHANGE SITE |
{{ pat.campLejeuneChangeSite }} |
| CAMP LEJEUNE DATA ENTRY LOCKED |
{{ pat.campLejeuneDataEntryLocked }} |
| CAMP LEJEUNE DATE |
{{ pat.campLejeuneDate }} |
| CAMP LEJEUNE SOURCE |
{{ pat.campLejeuneSource }} |
| CELLULAR NUMBER CHANGE DT/TM |
{{ pat.cellularNumberChangeDtTm }} |
| CELLULAR NUMBER CHANGE SITE |
{{ pat.cellularNumberChangeSite }} |
| CELLULAR NUMBER CHANGE SOURCE |
{{ pat.cellularNumberChangeSource }} |
| CHECK FOR DUPLICATE |
{{ pat.checkForDuplicate }} |
| CITY |
{{ pat.city }} |
| CITY (CIVIL) |
{{ pat.cityCivil }} |
| CITY (VA) |
{{ pat.cityVa }} |
| CLAIM NUMBER |
{{ pat.claimNumber }} |
| CLASS II DENTAL INDICATOR |
{{ pat.classIiDentalIndicator }} |
| CMOR ACTIVITY SCORE |
{{ pat.cmorActivityScore }} |
| CNH CURRENT |
{{ pat.cnhCurrent }} |
| COLLATERAL SPONSOR'S NAME |
{{ pat.collateralSponsorsName }} |
| COMBAT FROM DATE |
{{ pat.combatFromDate }} |
| COMBAT INDICATED ON 1010EZ |
{{ pat.combatIndicatedOn_1010ez }} |
| COMBAT SERVICE INDICATED? |
{{ pat.combatServiceIndicated }} |
| COMBAT SERVICE LOCATION |
{{ pat.combatServiceLocation }} |
| COMBAT TO DATE |
{{ pat.combatToDate }} |
| COMBAT VETERAN END DATE |
{{ pat.combatVeteranEndDate }} |
| CONDITION |
{{ pat.condition }} |
| CONFIDENTIAL ADDR CHANGE DT/TM |
{{ pat.confidentialAddrChangeDtTm }} |
| CONFIDENTIAL ADDR CHANGE SITE |
{{ pat.confidentialAddrChangeSite }} |
| CONFIDENTIAL ADDR COUNTRY |
{{ pat.confidentialAddrCountry }} |
| CONFIDENTIAL ADDR POSTAL CODE |
{{ pat.confidentialAddrPostalCode }} |
| CONFIDENTIAL ADDR PROVINCE |
{{ pat.confidentialAddrProvince }} |
| CONFIDENTIAL ADDRESS ACTIVE? |
{{ pat.confidentialAddressActive }} |
| CONFIDENTIAL ADDRESS CITY |
{{ pat.confidentialAddressCity }} |
| CONFIDENTIAL ADDRESS COUNTY |
{{ pat.confidentialAddressCounty }} |
| CONFIDENTIAL ADDRESS STATE |
{{ pat.confidentialAddressState }} |
| CONFIDENTIAL ADDRESS ZIP CODE |
{{ pat.confidentialAddressZipCode }} |
| CONFIDENTIAL END DATE |
{{ pat.confidentialEndDate }} |
| CONFIDENTIAL PHONE NUMBER |
{{ pat.confidentialPhoneNumber }} |
| CONFIDENTIAL START DATE |
{{ pat.confidentialStartDate }} |
| CONFIDENTIAL STREET [LINE 1] |
{{ pat.confidentialStreetLine_1 }} |
| CONFIDENTIAL STREET [LINE 2] |
{{ pat.confidentialStreetLine_2 }} |
| CONFIDENTIAL STREET [LINE 3] |
{{ pat.confidentialStreetLine_3 }} |
| COORDINATING MASTER OF RECORD |
{{ pat.coordinatingMasterOfRecord }} |
| COUNTRY |
{{ pat.country }} |
| COUNTY |
{{ pat.county }} |
| COVERED BY HEALTH INSURANCE? |
{{ pat.coveredByHealthInsurance }} |
| CURRENT ADMISSION |
{{ pat.currentAdmission }} |
| CURRENT ENROLLMENT |
{{ pat.currentEnrollment }} |
| CURRENT MEANS TEST STATUS |
{{ pat.currentMeansTestStatus }} |
| CURRENT MOH INDICATOR |
{{ pat.currentMohIndicator }} |
| CURRENT MOVEMENT |
{{ pat.currentMovement }} |
| CURRENT PH INDICATOR |
{{ pat.currentPhIndicator }} |
| CURRENT PURPLE HEART REMARKS |
{{ pat.currentPurpleHeartRemarks }} |
| CURRENT PURPLE HEART STATUS |
{{ pat.currentPurpleHeartStatus }} |
| CURRENT ROOM |
{{ pat.currentRoom }} |
| CV DATE EDITED |
{{ pat.cvDateEdited }} |
| D-CITY |
{{ pat.dCity }} |
| D-DESIGNEE SAME AS NOK? |
{{ pat.dDesigneeSameAsNok }} |
| D-NAME COMPONENTS |
{{ pat.dNameComponents }} |
| D-NAME OF DESIGNEE |
{{ pat.dNameOfDesignee }} |
| D-PHONE NUMBER |
{{ pat.dPhoneNumber }} |
| D-RELATIONSHIP TO PATIENT |
{{ pat.dRelationshipToPatient }} |
| D-STATE |
{{ pat.dState }} |
| D-STREET ADDRESS [LINE 1] |
{{ pat.dStreetAddressLine_1 }} |
| D-STREET ADDRESS [LINE 2] |
{{ pat.dStreetAddressLine_2 }} |
| D-STREET ADDRESS [LINE 3] |
{{ pat.dStreetAddressLine_3 }} |
| D-WORK PHONE NUMBER |
{{ pat.dWorkPhoneNumber }} |
| D-ZIP CODE |
{{ pat.dZipCode }} |
| D-ZIP+4 |
{{ pat.dZipPlus4 }} |
| DATE COMMENT LAST EDITED |
{{ pat.dateCommentLastEdited }} |
| DATE ENTERED INTO FILE |
{{ pat.dateEnteredIntoFile }} |
| DATE ENTERED ON SI LIST |
{{ pat.dateEnteredOnSiList }} |
| DATE FACILITY INITIATED REVIEW |
{{ pat.dateFacilityInitiatedReview }} |
| DATE MEDICAID LAST ASKED |
{{ pat.dateMedicaidLastAsked }} |
| DATE OF BIRTH |
{{ pat.dateOfBirth }} |
| DATE OF DEATH |
{{ pat.dateOfDeath }} |
| DATE OF DEATH LAST UPDATED |
{{ pat.dateOfDeathLastUpdated }} |
| DATE OF DECISION |
{{ pat.dateOfDecision }} |
| DATE OF RETIREMENT |
{{ pat.dateOfRetirement }} |
| DATE RULED INCOMPETENT (CIVIL) |
{{ pat.dateRuledIncompetentCivil }} |
| DATE RULED INCOMPETENT (VA) |
{{ pat.dateRuledIncompetentVa }} |
| DATE STATUS LAST EDITED |
{{ pat.dateStatusLastEdited }} |
| DATE VETERAN REQUESTED CD EVAL |
{{ pat.dateVeteranRequestedCdEval }} |
| DATE VETERAN WAS NOTIFIED |
{{ pat.dateVeteranWasNotified }} |
| DEATH ENTERED BY |
{{ pat.deathEnteredBy }} |
| DECIDED BY |
{{ pat.decidedBy }} |
| DENTAL APPL DUE BEFORE DATE |
{{ pat.dentalApplDueBeforeDate }} |
| DENTAL CLASSIFICATION |
{{ pat.dentalClassification }} |
| DENTAL ELIGIBILITY EXPIRATION |
{{ pat.dentalEligibilityExpiration }} |
| DESIGNEE CHANGE DATE/TIME |
{{ pat.designeeChangeDatetime }} |
| DISABILITY DISCHARGE ON 1010EZ |
{{ pat.disabilityDischargeOn_1010ez }} |
| DISABILITY RET. FROM MILITARY? |
{{ pat.disabilityRetFromMilitary }} |
| DISCHARGE DUE TO DISABILITY |
{{ pat.dischargeDueToDisability }} |
| DIVISION |
{{ pat.division }} |
| DUPLICATE STATUS |
{{ pat.duplicateStatus }} |
| E-CITY |
{{ pat.eCity }} |
| E-CONTACT CHANGE DATE/TIME |
{{ pat.eContactChangeDatetime }} |
| E-EMER. CONTACT SAME AS NOK? |
{{ pat.eEmerContactSameAsNok }} |
| E-NAME |
{{ pat.eName }} |
| E-NAME COMPONENTS |
{{ pat.eNameComponents }} |
| E-PHONE NUMBER |
{{ pat.ePhoneNumber }} |
| E-RELATIONSHIP TO PATIENT |
{{ pat.eRelationshipToPatient }} |
| E-STATE |
{{ pat.eState }} |
| E-STREET ADDRESS [LINE 1] |
{{ pat.eStreetAddressLine_1 }} |
| E-STREET ADDRESS [LINE 2] |
{{ pat.eStreetAddressLine_2 }} |
| E-STREET ADDRESS [LINE 3] |
{{ pat.eStreetAddressLine_3 }} |
| E-WORK PHONE NUMBER |
{{ pat.eWorkPhoneNumber }} |
| E-ZIP CODE |
{{ pat.eZipCode }} |
| E-ZIP+4 |
{{ pat.eZipPlus4 }} |
| E2-CITY |
{{ pat.e2City }} |
| E2-CONTACT CHANGE DATE/TIME |
{{ pat.e2ContactChangeDatetime }} |
| E2-NAME COMPONENTS |
{{ pat.e2NameComponents }} |
| E2-NAME OF SECONDARY CONTACT |
{{ pat.e2NameOfSecondaryContact }} |
| E2-PHONE NUMBER |
{{ pat.e2PhoneNumber }} |
| E2-RELATIONSHIP TO PATIENT |
{{ pat.e2RelationshipToPatient }} |
| E2-STATE |
{{ pat.e2State }} |
| E2-STREET ADDRESS [LINE 1] |
{{ pat.e2StreetAddressLine_1 }} |
| E2-STREET ADDRESS [LINE 2] |
{{ pat.e2StreetAddressLine_2 }} |
| E2-STREET ADDRESS [LINE 3] |
{{ pat.e2StreetAddressLine_3 }} |
| E2-WORK PHONE NUMBER |
{{ pat.e2WorkPhoneNumber }} |
| E2-ZIP CODE |
{{ pat.e2ZipCode }} |
| E2-ZIP+4 |
{{ pat.e2ZipPlus4 }} |
| EFF. DATE COMBINED SC% EVAL. |
{{ pat.effDateCombinedScEval }} |
| ELIGIBILITY INTERIM RESPONSE |
{{ pat.eligibilityInterimResponse }} |
| ELIGIBILITY STATUS |
{{ pat.eligibilityStatus }} |
| ELIGIBILITY STATUS DATE |
{{ pat.eligibilityStatusDate }} |
| ELIGIBILITY STATUS ENTERED BY |
{{ pat.eligibilityStatusEnteredBy }} |
| ELIGIBILITY VERIF. METHOD |
{{ pat.eligibilityVerifMethod }} |
| ELIGIBILITY VERIF. SOURCE |
{{ pat.eligibilityVerifSource }} |
| ELIGIBLE FOR MEDICAID? |
{{ pat.eligibleForMedicaid }} |
| EMAIL ADDRESS |
{{ pat.emailAddress }} |
| EMAIL ADDRESS CHANGE DT/TM |
{{ pat.emailAddressChangeDtTm }} |
| EMAIL ADDRESS CHANGE SITE |
{{ pat.emailAddressChangeSite }} |
| EMAIL ADDRESS CHANGE SOURCE |
{{ pat.emailAddressChangeSource }} |
| EMAIL ADDRESS INDICATOR |
{{ pat.emailAddressIndicator }} |
| EMAIL ADDRESS INDICATOR DT/TM |
{{ pat.emailAddressIndicatorDtTm }} |
| EMERGENCY RESPONSE INDICATOR |
{{ pat.emergencyResponseIndicator }} |
| EMPLOYER CITY |
{{ pat.employerCity }} |
| EMPLOYER NAME |
{{ pat.employerName }} |
| EMPLOYER PHONE NUMBER |
{{ pat.employerPhoneNumber }} |
| EMPLOYER STATE |
{{ pat.employerState }} |
| EMPLOYER STREET [LINE 1] |
{{ pat.employerStreetLine_1 }} |
| EMPLOYER STREET [LINE 2] |
{{ pat.employerStreetLine_2 }} |
| EMPLOYER STREET [LINE 3] |
{{ pat.employerStreetLine_3 }} |
| EMPLOYER ZIP CODE |
{{ pat.employerZipCode }} |
| EMPLOYER ZIP+4 |
{{ pat.employerZipPlus4 }} |
| EMPLOYMENT STATUS |
{{ pat.employmentStatus }} |
| EXCLUDE FROM FACILITY DIR |
{{ pat.excludeFromFacilityDir }} |
| FACILITY MAKING DETERMINATION |
{{ pat.facilityMakingDetermination }} |
| FATHER'S NAME |
{{ pat.fathersName }} |
| FATHER'S NAME COMPONENTS |
{{ pat.fathersNameComponents }} |
| FEE HOSPITAL I.D. |
{{ pat.feeHospitalID }} |
| FFF DATE ENTERED |
{{ pat.fffDateEntered }} |
| FFF DATE REMOVED |
{{ pat.fffDateRemoved }} |
| FFF ENTERED BY |
{{ pat.fffEnteredBy }} |
| FFF REMOVAL REMARKS |
{{ pat.fffRemovalRemarks }} |
| FFF REMOVED BY |
{{ pat.fffRemovedBy }} |
| FILIPINO VETERAN PROOF |
{{ pat.filipinoVeteranProof }} |
| FOREIGN ID NUMBER |
{{ pat.foreignIdNumber }} |
| FUGITIVE FELON FLAG |
{{ pat.fugitiveFelonFlag }} |
| FULL ICN |
{{ pat.fullIcn }} |
| GI INSURANCE POLICY? |
{{ pat.giInsurancePolicy }} |
| GOVERNMENT AGENCY |
{{ pat.governmentAgency }} |
| GRENADA FROM DATE |
{{ pat.grenadaFromDate }} |
| GRENADA SERVICE INDICATED? |
{{ pat.grenadaServiceIndicated }} |
| GRENADA TO DATE |
{{ pat.grenadaToDate }} |
| GUARDIAN (CIVIL) |
{{ pat.guardianCivil }} |
| GUARDIAN (VA) |
{{ pat.guardianVa }} |
| HOW WAS PATIENT ENTERED? |
{{ pat.howWasPatientEntered }} |
| ICN CHECKSUM |
{{ pat.icnChecksum }} |
| INELIGIBLE DATE |
{{ pat.ineligibleDate }} |
| INELIGIBLE REASON |
{{ pat.ineligibleReason }} |
| INELIGIBLE TWX CITY |
{{ pat.ineligibleTwxCity }} |
| INELIGIBLE TWX SOURCE |
{{ pat.ineligibleTwxSource }} |
| INELIGIBLE TWX STATE |
{{ pat.ineligibleTwxState }} |
| INELIGIBLE VARO DECISION |
{{ pat.ineligibleVaroDecision }} |
| INITIAL ODS TREATMENT RECEIVED |
{{ pat.initialOdsTreatmentReceived }} |
| INPATIENT WARD |
{{ pat.inpatientWard }} |
| INSTITUTION (CIVIL) |
{{ pat.institutionCivil }} |
| INSTITUTION (VA) |
{{ pat.institutionVa }} |
| INTEGRATION CONTROL NUMBER |
{{ pat.integrationControlNumber }} |
| K-ADDRESS SAME AS PATIENT'S? |
{{ pat.kAddressSameAsPatients }} |
| K-CITY |
{{ pat.kCity }} |
| K-NAME COMPONENTS |
{{ pat.kNameComponents }} |
| K-NAME OF PRIMARY NOK |
{{ pat.kNameOfPrimaryNok }} |
| K-PHONE NUMBER |
{{ pat.kPhoneNumber }} |
| K-RELATIONSHIP TO PATIENT |
{{ pat.kRelationshipToPatient }} |
| K-STATE |
{{ pat.kState }} |
| K-STREET ADDRESS [LINE 1] |
{{ pat.kStreetAddressLine_1 }} |
| K-STREET ADDRESS [LINE 2] |
{{ pat.kStreetAddressLine_2 }} |
| K-STREET ADDRESS [LINE 3] |
{{ pat.kStreetAddressLine_3 }} |
| K-WORK PHONE NUMBER |
{{ pat.kWorkPhoneNumber }} |
| K-ZIP CODE |
{{ pat.kZipCode }} |
| K-ZIP+4 |
{{ pat.kZipPlus4 }} |
| K2-ADDRESS SAME AS PATIENT'S? |
{{ pat.k2AddressSameAsPatients }} |
| K2-CITY |
{{ pat.k2City }} |
| K2-NAME COMPONENTS |
{{ pat.k2NameComponents }} |
| K2-NAME OF SECONDARY NOK |
{{ pat.k2NameOfSecondaryNok }} |
| K2-PHONE NUMBER |
{{ pat.k2PhoneNumber }} |
| K2-RELATIONSHIP TO PATIENT |
{{ pat.k2RelationshipToPatient }} |
| K2-STATE |
{{ pat.k2State }} |
| K2-STREET ADDRESS [LINE 1] |
{{ pat.k2StreetAddressLine_1 }} |
| K2-STREET ADDRESS [LINE 2] |
{{ pat.k2StreetAddressLine_2 }} |
| K2-STREET ADDRESS [LINE 3] |
{{ pat.k2StreetAddressLine_3 }} |
| K2-WORK PHONE NUMBER |
{{ pat.k2WorkPhoneNumber }} |
| K2-ZIP CODE |
{{ pat.k2ZipCode }} |
| K2-ZIP+4 |
{{ pat.k2ZipPlus4 }} |
| LAB REFERRAL REF |
{{ pat.labReferralRef }} |
| LABORATORY REFERENCE |
{{ pat.laboratoryReference }} |
| LAST DMMS EPISODE NUMBER |
{{ pat.lastDmmsEpisodeNumber }} |
| LAST EDITED BY |
{{ pat.lastEditedBy }} |
| LAST MEANS TEST |
{{ pat.lastMeansTest }} |
| LEBANON FROM DATE |
{{ pat.lebanonFromDate }} |
| LEBANON SERVICE INDICATED? |
{{ pat.lebanonServiceIndicated }} |
| LEBANON TO DATE |
{{ pat.lebanonToDate }} |
| LOCALLY ASSIGNED ICN |
{{ pat.locallyAssignedIcn }} |
| LODGER WARD LOCATION |
{{ pat.lodgerWardLocation }} |
| MARITAL STATUS |
{{ pat.maritalStatus }} |
| MEDICAID NUMBER |
{{ pat.medicaidNumber }} |
| METHOD OF DETERMINATION |
{{ pat.methodOfDetermination }} |
| MILITARY DISABILITY RETIREMENT |
{{ pat.militaryDisabilityRetirement }} |
| MISSING PERSON DATE |
{{ pat.missingPersonDate }} |
| MISSING PERSON TWX CITY |
{{ pat.missingPersonTwxCity }} |
| MISSING PERSON TWX SOURCE |
{{ pat.missingPersonTwxSource }} |
| MISSING PERSON TWX STATE |
{{ pat.missingPersonTwxState }} |
| MONETARY BEN. VERIFY DATE |
{{ pat.monetaryBenVerifyDate }} |
| MOST RECENT 1010EZ |
{{ pat.mostRecent_1010ez }} |
| MOST RECENT DATE OF CARE |
{{ pat.mostRecentDateOfCare }} |
| MOST RECENT LOCATION OF CARE |
{{ pat.mostRecentLocationOfCare }} |
| MOTHER'S MAIDEN NAME |
{{ pat.mothersMaidenName }} |
| MOTHER'S NAME |
{{ pat.mothersName }} |
| MOTHER'S NAME COMPONENTS |
{{ pat.mothersNameComponents }} |
| MOTHERS MAIDEN NAME COMPONENTS |
{{ pat.mothersMaidenNameComponents }} |
| MULTIPLE BIRTH INDICATOR |
{{ pat.multipleBirthIndicator }} |
| NAME |
{{ pat.name }} |
| NAME COMPONENTS |
{{ pat.nameComponents }} |
| NETWORK IDENTIFIER |
{{ pat.networkIdentifier }} |
| OCCUPATION |
{{ pat.occupation }} |
| P&T |
{{ pat.pT }} |
| P&T EFFECTIVE DATE |
{{ pat.pTEffectiveDate }} |
| PAGER NUMBER |
{{ pat.pagerNumber }} |
| PAGER NUMBER CHANGE DT/TM |
{{ pat.pagerNumberChangeDtTm }} |
| PAGER NUMBER CHANGE SITE |
{{ pat.pagerNumberChangeSite }} |
| PAGER NUMBER CHANGE SOURCE |
{{ pat.pagerNumberChangeSource }} |
| PANAMA FROM DATE |
{{ pat.panamaFromDate }} |
| PANAMA SERVICE INDICATED? |
{{ pat.panamaServiceIndicated }} |
| PANAMA TO DATE |
{{ pat.panamaToDate }} |
| PATIENT MERGED TO |
{{ pat.patientMergedTo }} |
| PENSION AWARD EFFECTIVE DATE |
{{ pat.pensionAwardEffectiveDate }} |
| PENSION AWARD LOCK |
{{ pat.pensionAwardLock }} |
| PENSION AWARD REASON |
{{ pat.pensionAwardReason }} |
| PENSION INDICATOR LOCK |
{{ pat.pensionIndicatorLock }} |
| PENSION TERMINATED DATE |
{{ pat.pensionTerminatedDate }} |
| PENSION TERMINATED REASON 1 |
{{ pat.pensionTerminatedReason_1 }} |
| PENSION TERMINATED REASON 2 |
{{ pat.pensionTerminatedReason_2 }} |
| PENSION TERMINATED REASON 3 |
{{ pat.pensionTerminatedReason_3 }} |
| PENSION TERMINATED REASON 4 |
{{ pat.pensionTerminatedReason_4 }} |
| PERIOD OF SERVICE |
{{ pat.periodOfService }} |
| PERSIAN GULF FROM DATE |
{{ pat.persianGulfFromDate }} |
| PERSIAN GULF SERVICE? |
{{ pat.persianGulfService }} |
| PERSIAN GULF TO DATE |
{{ pat.persianGulfToDate }} |
| PH DIVISION |
{{ pat.phDivision }} |
| PHONE (CIVIL) |
{{ pat.phoneCivil }} |
| PHONE (VA) |
{{ pat.phoneVa }} |
| PHONE NUMBER [CELLULAR] |
{{ pat.phoneNumberCellular }} |
| PHONE NUMBER [RESIDENCE] |
{{ pat.phoneNumberResidence }} |
| PHONE NUMBER [WORK] |
{{ pat.phoneNumberWork }} |
| PLACE OF BIRTH [CITY] |
{{ pat.placeOfBirthCity }} |
| PLACE OF BIRTH [STATE] |
{{ pat.placeOfBirthState }} |
| POSTAL CODE |
{{ pat.postalCode }} |
| POW CONFINEMENT LOCATION |
{{ pat.powConfinementLocation }} |
| POW FROM DATE |
{{ pat.powFromDate }} |
| POW STATUS INDICATED? |
{{ pat.powStatusIndicated }} |
| POW STATUS VERIFIED |
{{ pat.powStatusVerified }} |
| POW TO DATE |
{{ pat.powToDate }} |
| PREFERRED FACILITY |
{{ pat.preferredFacility }} |
| PRIMARY ELIGIBILITY CODE |
{{ pat.primaryEligibilityCode }} |
| PRIMARY LONG ID |
{{ pat.primaryLongId }} |
| PRIMARY NOK CHANGE DATE/TIME |
{{ pat.primaryNokChangeDatetime }} |
| PRIMARY SHORT ID |
{{ pat.primaryShortId }} |
| PROJ 112/SHAD |
{{ pat.proj_112shad }} |
| PROVIDER |
{{ pat.provider }} |
| PROVINCE |
{{ pat.province }} |
| PSEUDO SSN REASON |
{{ pat.pseudoSsnReason }} |
| RACE |
{{ pat.race }} |
| RADIATION EXPOSURE INDICATED? |
{{ pat.radiationExposureIndicated }} |
| RADIATION EXPOSURE METHOD |
{{ pat.radiationExposureMethod }} |
| RADIATION REGISTRATION DATE |
{{ pat.radiationRegistrationDate }} |
| RANK |
{{ pat.rank }} |
| RATED INCOMPETENT? |
{{ pat.ratedIncompetent }} |
| RECALLED TO ACTIVE DUTY |
{{ pat.recalledToActiveDuty }} |
| RECEIVED VA CARE PREVIOUSLY? |
{{ pat.receivedVaCarePreviously }} |
| RECEIVING A VA PENSION? |
{{ pat.receivingAVaPension }} |
| RECEIVING A&A BENEFITS? |
{{ pat.receivingAaBenefits }} |
| RECEIVING HOUSEBOUND BENEFITS? |
{{ pat.receivingHouseboundBenefits }} |
| RECEIVING MILITARY RETIREMENT? |
{{ pat.receivingMilitaryRetirement }} |
| RECEIVING SOCIAL SECURITY? |
{{ pat.receivingSocialSecurity }} |
| RECEIVING SUP. SECURITY (SSI)? |
{{ pat.receivingSupSecuritySsi }} |
| RECEIVING VA DISABILITY? |
{{ pat.receivingVaDisability }} |
| RELATIONSHIP (CIVIL) |
{{ pat.relationshipCivil }} |
| RELATIONSHIP (VA) |
{{ pat.relationshipVa }} |
| RELIGIOUS PREFERENCE |
{{ pat.religiousPreference }} |
| REMARKS |
{{ pat.remarks }} |
| RESIDENCE NUMBER CHANGE DT/TM |
{{ pat.residenceNumberChangeDttm }} |
| RESIDENCE NUMBER CHANGE SITE |
{{ pat.residenceNumberChangeSite }} |
| RESIDENCE NUMBER CHANGE SOURCE |
{{ pat.residenceNumberChangeSource }} |
| REVIEW DATE |
{{ pat.reviewDate }} |
| ROOM-BED |
{{ pat.roomBed }} |
| SC AWARD DATE |
{{ pat.scAwardDate }} |
| SCORE CALCULATION DATE |
{{ pat.scoreCalculationDate }} |
| SECONDARY NOK CHANGE DATE/TIME |
{{ pat.secondaryNokChangeDatetime }} |
| SELF IDENTIFIED GENDER |
{{ pat.selfIdentifiedGender }} |
| SERVICE BRANCH [LAST] |
{{ pat.serviceBranchLast }} |
| SERVICE BRANCH [NNTL] |
{{ pat.serviceBranchNntl }} |
| SERVICE BRANCH [NTL] |
{{ pat.serviceBranchNtl }} |
| SERVICE COMPONENT [LAST] |
{{ pat.serviceComponentLast }} |
| SERVICE COMPONENT [NNTL] |
{{ pat.serviceComponentNntl }} |
| SERVICE COMPONENT [NTL] |
{{ pat.serviceComponentNtl }} |
| SERVICE CONNECTED PERCENTAGE |
{{ pat.serviceConnectedPercentage }} |
| SERVICE CONNECTED? |
{{ pat.serviceConnected }} |
| SERVICE DENTAL INJURY? |
{{ pat.serviceDentalInjury }} |
| SERVICE DISCHARGE TYPE [LAST] |
{{ pat.serviceDischargeTypeLast }} |
| SERVICE DISCHARGE TYPE [NNTL] |
{{ pat.serviceDischargeTypeNntl }} |
| SERVICE DISCHARGE TYPE [NTL] |
{{ pat.serviceDischargeTypeNtl }} |
| SERVICE ENTRY DATE [LAST] |
{{ pat.serviceEntryDateLast }} |
| SERVICE ENTRY DATE [NNTL] |
{{ pat.serviceEntryDateNntl }} |
| SERVICE ENTRY DATE [NTL] |
{{ pat.serviceEntryDateNtl }} |
| SERVICE NUMBER [LAST] |
{{ pat.serviceNumberLast }} |
| SERVICE NUMBER [NNTL] |
{{ pat.serviceNumberNntl }} |
| SERVICE NUMBER [NTL] |
{{ pat.serviceNumberNtl }} |
| SERVICE SECOND EPISODE? |
{{ pat.serviceSecondEpisode }} |
| SERVICE SEPARATION DATE [LAST] |
{{ pat.serviceSeparationDateLast }} |
| SERVICE SEPARATION DATE [NNTL] |
{{ pat.serviceSeparationDateNntl }} |
| SERVICE SEPARATION DATE [NTL] |
{{ pat.serviceSeparationDateNtl }} |
| SERVICE TEETH EXTRACTED? |
{{ pat.serviceTeethExtracted }} |
| SERVICE THIRD EPISODE? |
{{ pat.serviceThirdEpisode }} |
| SERVICE VERIFICATION DATE |
{{ pat.serviceVerificationDate }} |
| SEX |
{{ pat.sex }} |
| SOCIAL SECURITY NUMBER |
{{ pat.socialSecurityNumber }} |
| SOMALIA FROM DATE |
{{ pat.somaliaFromDate }} |
| SOMALIA SERVICE INDICATED? |
{{ pat.somaliaServiceIndicated }} |
| SOMALIA TO DATE |
{{ pat.somaliaToDate }} |
| SOURCE DESIGNATION |
{{ pat.sourceDesignation }} |
| SOURCE OF NOTIFICATION |
{{ pat.sourceOfNotification }} |
| SOUTHWEST ASIA CONDITIONS? |
{{ pat.southwestAsiaConditions }} |
| SPINAL CORD INJURY |
{{ pat.spinalCordInjury }} |
| SPOUSE'S EMP PHONE NUMBER |
{{ pat.spousesEmpPhoneNumber }} |
| SPOUSE'S EMP STREET [LINE 1] |
{{ pat.spousesEmpStreetLine_1 }} |
| SPOUSE'S EMP STREET [LINE 2] |
{{ pat.spousesEmpStreetLine_2 }} |
| SPOUSE'S EMP STREET [LINE 3] |
{{ pat.spousesEmpStreetLine_3 }} |
| SPOUSE'S EMP ZIP CODE |
{{ pat.spousesEmpZipCode }} |
| SPOUSE'S EMP ZIP+4 |
{{ pat.spousesEmpZipPlus4 }} |
| SPOUSE'S EMPLOYER NAME |
{{ pat.spousesEmployerName }} |
| SPOUSE'S EMPLOYER'S CITY |
{{ pat.spousesEmployersCity }} |
| SPOUSE'S EMPLOYER'S STATE |
{{ pat.spousesEmployersState }} |
| SPOUSE'S EMPLOYMENT STATUS |
{{ pat.spousesEmploymentStatus }} |
| SPOUSE'S OCCUPATION |
{{ pat.spousesOccupation }} |
| SPOUSE'S RETIREMENT DATE |
{{ pat.spousesRetirementDate }} |
| SSN VERIFICATION STATUS |
{{ pat.ssnVerificationStatus }} |
| STATE |
{{ pat.state }} |
| STATE (CIVIL) |
{{ pat.stateCivil }} |
| STATE (VA) |
{{ pat.stateVa }} |
| STREET ADDRESS 1 (CIVIL) |
{{ pat.streetAddress_1Civil }} |
| STREET ADDRESS 1 (VA) |
{{ pat.streetAddress_1Va }} |
| STREET ADDRESS 2 (CIVIL) |
{{ pat.streetAddress_2Civil }} |
| STREET ADDRESS 2 (VA) |
{{ pat.streetAddress_2Va }} |
| STREET ADDRESS [LINE 1] |
{{ pat.streetAddressLine_1 }} |
| STREET ADDRESS [LINE 2] |
{{ pat.streetAddressLine_2 }} |
| STREET ADDRESS [LINE 3] |
{{ pat.streetAddressLine_3 }} |
| SUBSCRIPTION CONTROL NUMBER |
{{ pat.subscriptionControlNumber }} |
| SW ASIA COND EXAM DATE |
{{ pat.swAsiaCondExamDate }} |
| SW ASIA COND REGISTRATION DATE |
{{ pat.swAsiaCondRegistrationDate }} |
| TEMPORARY ADDRESS ACTIVE? |
{{ pat.temporaryAddressActive }} |
| TEMPORARY ADDRESS CHANGE DT/TM |
{{ pat.temporaryAddressChangeDttm }} |
| TEMPORARY ADDRESS CHANGE SITE |
{{ pat.temporaryAddressChangeSite }} |
| TEMPORARY ADDRESS COUNTRY |
{{ pat.temporaryAddressCountry }} |
| TEMPORARY ADDRESS COUNTY |
{{ pat.temporaryAddressCounty }} |
| TEMPORARY ADDRESS END DATE |
{{ pat.temporaryAddressEndDate }} |
| TEMPORARY ADDRESS POSTAL CODE |
{{ pat.temporaryAddressPostalCode }} |
| TEMPORARY ADDRESS PROVINCE |
{{ pat.temporaryAddressProvince }} |
| TEMPORARY ADDRESS START DATE |
{{ pat.temporaryAddressStartDate }} |
| TEMPORARY CITY |
{{ pat.temporaryCity }} |
| TEMPORARY ID NUMBER |
{{ pat.temporaryIdNumber }} |
| TEMPORARY PHONE NUMBER |
{{ pat.temporaryPhoneNumber }} |
| TEMPORARY STATE |
{{ pat.temporaryState }} |
| TEMPORARY STREET [LINE 1] |
{{ pat.temporaryStreetLine_1 }} |
| TEMPORARY STREET [LINE 2] |
{{ pat.temporaryStreetLine_2 }} |
| TEMPORARY STREET [LINE 3] |
{{ pat.temporaryStreetLine_3 }} |
| TEMPORARY ZIP CODE |
{{ pat.temporaryZipCode }} |
| TEMPORARY ZIP+4 |
{{ pat.temporaryZipPlus4 }} |
| TERMINAL DIGIT OF SSN |
{{ pat.terminalDigitOfSsn }} |
| TEST PATIENT INDICATOR |
{{ pat.testPatientIndicator }} |
| TOTAL ANNUAL VA CHECK AMOUNT |
{{ pat.totalAnnualVaCheckAmount }} |
| TREATING SPECIALTY |
{{ pat.treatingSpecialty }} |
| TYPE |
{{ pat.type }} |
| TYPE OF OTHER RETIREMENT |
{{ pat.typeOfOtherRetirement }} |
| UNEMPLOYABLE |
{{ pat.unemployable }} |
| USER ENROLLEE SITE |
{{ pat.userEnrolleeSite }} |
| USER ENROLLEE VALID THROUGH |
{{ pat.userEnrolleeValidThrough }} |
| VETERAN (Y/N)? |
{{ pat.veteranYn }} |
| VETERAN CATASTROPHICALLY DISABLED? |
{{ pat.veteranCatastrophicallyDisabled }} |
| VIETNAM FROM DATE |
{{ pat.vietnamFromDate }} |
| VIETNAM SERVICE INDICATED? |
{{ pat.vietnamServiceIndicated }} |
| VIETNAM TO DATE |
{{ pat.vietnamToDate }} |
| VTS PATIENT FLAG |
{{ pat.vtsPatientFlag }} |
| WARD LOCATION |
{{ pat.wardLocation }} |
| WHO ENTERED PATIENT |
{{ pat.whoEnteredPatient }} |
| YUGOSLAVIA FROM DATE |
{{ pat.yugoslaviaFromDate }} |
| YUGOSLAVIA SERVICE INDICATED? |
{{ pat.yugoslaviaServiceIndicated }} |
| YUGOSLAVIA TO DATE |
{{ pat.yugoslaviaToDate }} |
| ZIP (CIVIL) |
{{ pat.zipCivil }} |
| ZIP (VA) |
{{ pat.zipVa }} |
| ZIP CODE |
{{ pat.zipCode }} |
| ZIP+4 |
{{ pat.zipPlus4 }} |
| ZIP+4 (CIVIL) |
{{ pat.zipPlus4Civil }} |
| ZIP+4 (VA) |
{{ pat.zipPlus4Va }} |
| ALIAS.ALIAS[1] |
{{ pat.aliasAlias }} |
| ALIAS.ALIAS COMPONENTS[1] |
{{ pat.aliasAliasComponents }} |
| ALIAS.ALIAS SSN[1] |
{{ pat.aliasAliasSsn }} |
| ALIAS.ALIAS[2] |
{{ pat.aliasAlias2 }} |
| ALIAS.ALIAS COMPONENTS[2] |
{{ pat.aliasAliasComponents2 }} |
| ALIAS.ALIAS SSN[2] |
{{ pat.aliasAliasSsn2 }} |
| INSURANCE TYPE.*COMMENT - PATIENT POLICY[1] |
{{ pat.insuranceTypeCommentPatientPolicy }} |
| INSURANCE TYPE.*GROUP NAME[1] |
{{ pat.insuranceTypeGroupName }} |
| INSURANCE TYPE.*GROUP NUMBER[1] |
{{ pat.insuranceTypeGroupNumber }} |
| INSURANCE TYPE.*NAME OF INSURED[1] |
{{ pat.insuranceTypeNameOfInsured }} |
| INSURANCE TYPE.*SUBSCRIBER ID[1] |
{{ pat.insuranceTypeSubscriberId }} |
| INSURANCE TYPE.COORDINATION OF BENEFITS[1] |
{{ pat.insuranceTypeCoordinationOfBenefits }} |
| INSURANCE TYPE.DATE ENTERED[1] |
{{ pat.insuranceTypeDateEntered }} |
| INSURANCE TYPE.DATE LAST EDITED[1] |
{{ pat.insuranceTypeDateLastEdited }} |
| INSURANCE TYPE.DATE LAST VERIFIED[1] |
{{ pat.insuranceTypeDateLastVerified }} |
| INSURANCE TYPE.DATE OF SOURCE OF INFORMATION[1] |
{{ pat.insuranceTypeDateOfSourceOfInformation }} |
| INSURANCE TYPE.DATE TIME PERIOD[1] |
{{ pat.insuranceTypeDatetimePeriod }} |
| INSURANCE TYPE.DATE TIME PERIOD FORMAT QUAL[1] |
{{ pat.insuranceTypeDatetimePeriodFormatQual }} |
| INSURANCE TYPE.EB DISPLAY ENTRY[1] |
{{ pat.insuranceTypeEbDisplayEntry }} |
| INSURANCE TYPE.EFFECTIVE DATE OF POLICY[1] |
{{ pat.insuranceTypeEffectiveDateOfPolicy }} |
| INSURANCE TYPE.EIV AUTO-UPDATE[1] |
{{ pat.insuranceTypeEivAutoUpdate }} |
| INSURANCE TYPE.EMPLOY CLAIM ST ADDRESS LINE 2[1] |
{{ pat.insuranceTypeEmployClaimStAddressLine_2 }} |
| INSURANCE TYPE.EMPLOY CLAIM ST ADDRESS LINE 3[1] |
{{ pat.insuranceTypeEmployClaimStAddressLine_3 }} |
| INSURANCE TYPE.EMPLOYER CLAIMS CITY[1] |
{{ pat.insuranceTypeEmployerClaimsCity }} |
| INSURANCE TYPE.EMPLOYER CLAIMS PHONE[1] |
{{ pat.insuranceTypeEmployerClaimsPhone }} |
| INSURANCE TYPE.EMPLOYER CLAIMS STATE[1] |
{{ pat.insuranceTypeEmployerClaimsState }} |
| INSURANCE TYPE.EMPLOYER CLAIMS STREET ADDRESS[1] |
{{ pat.insuranceTypeEmployerClaimsStreetAddress }} |
| INSURANCE TYPE.EMPLOYER CLAIMS ZIP CODE[1] |
{{ pat.insuranceTypeEmployerClaimsZipCode }} |
| INSURANCE TYPE.EMPLOYMENT STATUS[1] |
{{ pat.insuranceTypeEmploymentStatus }} |
| INSURANCE TYPE.ENTERED BY[1] |
{{ pat.insuranceTypeEnteredBy }} |
| INSURANCE TYPE.ESGHP[1] |
{{ pat.insuranceTypeEsghp }} |
| INSURANCE TYPE.GROUP PLAN[1] |
{{ pat.insuranceTypeGroupPlan }} |
| INSURANCE TYPE.INSURANCE EXPIRATION DATE[1] |
{{ pat.insuranceTypeInsuranceExpirationDate }} |
| INSURANCE TYPE.INSURANCE TYPE[1] |
{{ pat.insuranceTypeInsuranceType }} |
| INSURANCE TYPE.INSURED'S BRANCH[1] |
{{ pat.insuranceTypeInsuredsBranch }} |
| INSURANCE TYPE.INSURED'S CITY[1] |
{{ pat.insuranceTypeInsuredsCity }} |
| INSURANCE TYPE.INSURED'S COUNTRY[1] |
{{ pat.insuranceTypeInsuredsCountry }} |
| INSURANCE TYPE.INSURED'S COUNTRY SUBDIVISION[1] |
{{ pat.insuranceTypeInsuredsCountrySubdivision }} |
| INSURANCE TYPE.INSURED'S DOB[1] |
{{ pat.insuranceTypeInsuredsDob }} |
| INSURANCE TYPE.INSURED'S PHONE[1] |
{{ pat.insuranceTypeInsuredsPhone }} |
| INSURANCE TYPE.INSURED'S RANK[1] |
{{ pat.insuranceTypeInsuredsRank }} |
| INSURANCE TYPE.INSURED'S SEX[1] |
{{ pat.insuranceTypeInsuredsSex }} |
| INSURANCE TYPE.INSURED'S SSN[1] |
{{ pat.insuranceTypeInsuredsSsn }} |
| INSURANCE TYPE.INSURED'S STATE[1] |
{{ pat.insuranceTypeInsuredsState }} |
| INSURANCE TYPE.INSURED'S STREET 1[1] |
{{ pat.insuranceTypeInsuredsStreet_1 }} |
| INSURANCE TYPE.INSURED'S STREET 2[1] |
{{ pat.insuranceTypeInsuredsStreet_2 }} |
| INSURANCE TYPE.INSURED'S ZIP[1] |
{{ pat.insuranceTypeInsuredsZip }} |
| INSURANCE TYPE.LAST EDITED BY[1] |
{{ pat.insuranceTypeLastEditedBy }} |
| INSURANCE TYPE.MILITARY EMPLOYMENT STATUS[1] |
{{ pat.insuranceTypeMilitaryEmploymentStatus }} |
| INSURANCE TYPE.MILITARY GOVT AFFILIATION CODE[1] |
{{ pat.insuranceTypeMilitaryGovtAffiliationCode }} |
| INSURANCE TYPE.MILITARY INFO STATUS CODE[1] |
{{ pat.insuranceTypeMilitaryInfoStatusCode }} |
| INSURANCE TYPE.MILITARY PERSONNEL DESCRIPTION[1] |
{{ pat.insuranceTypeMilitaryPersonnelDescription }} |
| INSURANCE TYPE.MILITARY SERVICE RANK CODE[1] |
{{ pat.insuranceTypeMilitaryServiceRankCode }} |
| INSURANCE TYPE.NEW GROUP NAME[1] |
{{ pat.insuranceTypeNewGroupName }} |
| INSURANCE TYPE.NEW GROUP NUMBER[1] |
{{ pat.insuranceTypeNewGroupNumber }} |
| INSURANCE TYPE.PATIENT ID[1] |
{{ pat.insuranceTypePatientId }} |
| INSURANCE TYPE.PATIENT'S SEC QUALIFIER(1)[1] |
{{ pat.insuranceTypePatientsSecQualifier_1 }} |
| INSURANCE TYPE.PATIENT'S SEC QUALIFIER(2)[1] |
{{ pat.insuranceTypePatientsSecQualifier_2 }} |
| INSURANCE TYPE.PATIENT'S SEC QUALIFIER(3)[1] |
{{ pat.insuranceTypePatientsSecQualifier_3 }} |
| INSURANCE TYPE.PATIENT'S SECONDARY ID(1)[1] |
{{ pat.insuranceTypePatientsSecondaryId_1 }} |
| INSURANCE TYPE.PATIENT'S SECONDARY ID(2)[1] |
{{ pat.insuranceTypePatientsSecondaryId_2 }} |
| INSURANCE TYPE.PATIENT'S SECONDARY ID(3)[1] |
{{ pat.insuranceTypePatientsSecondaryId_3 }} |
| INSURANCE TYPE.PHARMACY PERSON CODE[1] |
{{ pat.insuranceTypePharmacyPersonCode }} |
| INSURANCE TYPE.PHARMACY RELATIONSHIP CODE[1] |
{{ pat.insuranceTypePharmacyRelationshipCode }} |
| INSURANCE TYPE.PRIMARY CARE PROVIDER[1] |
{{ pat.insuranceTypePrimaryCareProvider }} |
| INSURANCE TYPE.PRIMARY PROVIDER PHONE[1] |
{{ pat.insuranceTypePrimaryProviderPhone }} |
| INSURANCE TYPE.PT. RELATIONSHIP - HIPAA[1] |
{{ pat.insuranceTypePtRelationshipHipaa }} |
| INSURANCE TYPE.PT. RELATIONSHIP TO INSURED[1] |
{{ pat.insuranceTypePtRelationshipToInsured }} |
| INSURANCE TYPE.REQUESTED SERVICE DATE[1] |
{{ pat.insuranceTypeRequestedServiceDate }} |
| INSURANCE TYPE.REQUESTED SERVICE TYPE[1] |
{{ pat.insuranceTypeRequestedServiceType }} |
| INSURANCE TYPE.RETIREMENT DATE[1] |
{{ pat.insuranceTypeRetirementDate }} |
| INSURANCE TYPE.SEND BILL TO EMPLOYER[1] |
{{ pat.insuranceTypeSendBillToEmployer }} |
| INSURANCE TYPE.SOURCE OF INFORMATION[1] |
{{ pat.insuranceTypeSourceOfInformation }} |
| INSURANCE TYPE.STOP POLICY FROM BILLING[1] |
{{ pat.insuranceTypeStopPolicyFromBilling }} |
| INSURANCE TYPE.SUBSCRIBER'S EMPLOYER NAME[1] |
{{ pat.insuranceTypeSubscribersEmployerName }} |
| INSURANCE TYPE.SUBSCRIBER'S SEC ID(1)[1] |
{{ pat.insuranceTypeSubscribersSecId_1 }} |
| INSURANCE TYPE.SUBSCRIBER'S SEC ID(2)[1] |
{{ pat.insuranceTypeSubscribersSecId_2 }} |
| INSURANCE TYPE.SUBSCRIBER'S SEC ID(3)[1] |
{{ pat.insuranceTypeSubscribersSecId_3 }} |
| INSURANCE TYPE.SUBSCRIBER'S SEC QUALIFIER(1)[1] |
{{ pat.insuranceTypeSubscribersSecQualifier_1 }} |
| INSURANCE TYPE.SUBSCRIBER'S SEC QUALIFIER(2)[1] |
{{ pat.insuranceTypeSubscribersSecQualifier_2 }} |
| INSURANCE TYPE.SUBSCRIBER'S SEC QUALIFIER(3)[1] |
{{ pat.insuranceTypeSubscribersSecQualifier_3 }} |
| INSURANCE TYPE.VERIFIED BY[1] |
{{ pat.insuranceTypeVerifiedBy }} |
| INSURANCE TYPE.WHOSE INSURANCE[1] |
{{ pat.insuranceTypeWhoseInsurance }} |