????!@&@x1Courier Newx1Courier New㥛 ?y&1?㥛 ?K7A`?XdTimes New Romann@h|?@jt?K7A`?x1Courier New?^I +@MbX?MbX?%02mx1Courier Newx&1?^I +@\(\?MbX?%02Dx1Courier NewS?^I +@\(\?MbX?%Yx1Courier Newy&1?^I +@MbX?MbX?%02mx1Courier New?^I +@\(\?MbX?%02Dx1Courier New?^I +@x&1?MbX?%Yx1Courier New/$@^I +@?MbX?x1Courier New^I +@^I +@?MbX?x1Courier Newn @^I +@?MbX?x1Courier New^I +@^I +@MbX?MbX?Zx1Courier NewnJ@^I +@MbX?MbX?[x1Courier New@^I +@MbX?MbX?x1Courier Newn@^I +@MbX?MbX?%1tx1Courier New(\u@^I +@MbX?MbX?%dx1Courier New^I +@^I +@MbX?MbX?%02c$x1Courier NewK7A`@^I +@x&1?MbX?if [Claim Detail - Anesthesia Minutes] = "0" then [Claim Detail - Units] else [Claim Detail - Anesthesia Minutes] endif x1Courier New^I @@K7A`?㥛 ?x1Courier Newn@@5^I ?㥛 ?@x1Courier Newn@^I +@/$?MbX?dTimes New Romann@^I +@㥛 ?MbX?x1Courier New?@MbX?MbX?%02mx1Courier Newx&1?@\(\?MbX?%02Dx1Courier NewS?@\(\?MbX?%Yx1Courier Newy&1?@MbX?MbX?%02mx1Courier New?@\(\?MbX?%02Dx1Courier New?@x&1?MbX?%Yx1Courier New/$@@?MbX?x1Courier New^I +@@?MbX?x1Courier Newn @@?MbX?x1Courier New^I +@@MbX?MbX?Zx1Courier NewnJ@@MbX?MbX?[x1Courier New@@MbX?MbX?x1Courier Newn@@MbX?MbX?%1tx1Courier New(\u@@MbX?MbX?%dx1Courier New^I +@@MbX?MbX?%02c$x1Courier NewK7A`@@MbX?MbX?if [Claim Detail - Anesthesia Minutes] = "0" then [Claim Detail - Units] else [Claim Detail - Anesthesia Minutes] endif x1Courier New^I @"~@Mb?㥛 ?x1Courier Newn@"~@5^I ?㥛 ?@x1Courier Newn@@/$?MbX?dTimes New Romann@@㥛 ?MbX?x1Courier New?"~j @MbX?MbX?%02mx1Courier Newx&1?L7A`e @\(\?MbX?%02Dx1Courier NewS?L7A`e @\(\?MbX?%Yx1Courier Newy&1?L7A`e @MbX?MbX?%02mx1Courier New?L7A`e @\(\?MbX?%02Dx1Courier New?L7A`e @x&1?MbX?%Yx1Courier New/$@L7A`e @?MbX?x1Courier New^I +@L7A`e @?MbX?x1Courier Newn @L7A`e @?MbX?x1Courier New^I +@L7A`e @MbX?MbX?Zx1Courier NewnJ@L7A`e @MbX?MbX?[x1Courier New@L7A`e @MbX?MbX?x1Courier Newn@L7A`e @MbX?MbX?%1tx1Courier New(\u@L7A`e @MbX?MbX?%dx1Courier New^I +@L7A`e @MbX?MbX?%02c$x1Courier NewK7A`@L7A`e @Mb?MbX?if [Claim Detail - Anesthesia Minutes] = "0" then [Claim Detail - Units] else [Claim Detail - Anesthesia Minutes] endif x1Courier New^I @/$ @Mb?㥛 ?x1Courier Newn@/$ @5^I ?㥛 ?@x1Courier Newn@L7A`e @/$?MbX?dTimes New Romann@L7A`e @㥛 ?MbX?x1Courier New?/$!@MbX?MbX?%02mx1Courier Newx&1?/$!@\(\?MbX?%02Dx1Courier NewS?/$!@\(\?MbX?%Yx1Courier Newy&1?/$!@MbX?MbX?%02mx1Courier New?/$!@\(\?MbX?%02Dx1Courier New?/$!@x&1?MbX?%Yx1Courier New/$@/$!@?MbX?x1Courier New^I +@/$!@?MbX?x1Courier Newn @/$!@?MbX?x1Courier New^I +@/$!@MbX?MbX?Zx1Courier NewnJ@/$!@MbX?MbX?[x1Courier New@/$!@MbX?MbX?x1Courier Newn@/$!@MbX?MbX?%1tx1Courier New(\u@/$!@MbX?MbX?%dx1Courier New^I +@/$!@MbX?MbX?%02c$x1Courier NewK7A`@/$!@x&1?MbX?if [Claim Detail - Anesthesia Minutes] = "0" then [Claim Detail - Units] else [Claim Detail - Anesthesia Minutes] endif x1Courier New^I @Q @Mb?㥛 ?x1Courier Newn@Q @5^I ?㥛 ?@x1Courier Newn@/$!@/$?MbX?dTimes New Romann@/$!@㥛 ?MbX?x1Courier New?Q!@MbX?MbX?%02mx1Courier Newx&1?Q!@\(\?MbX?%02Dx1Courier NewS?Q!@\(\?MbX?%Yx1Courier Newy&1?Q!@MbX?MbX?%02mx1Courier New?Q!@\(\?MbX?%02Dx1Courier New?Q!@x&1?MbX?%Yx1Courier New/$@Q!@?MbX?x1Courier New^I +@Q!@?MbX?x1Courier Newn @Q!@?MbX?x1Courier New^I +@Q!@MbX?MbX?Zx1Courier NewnJ@Q!@MbX?MbX?[x1Courier New@Q!@MbX?MbX?x1Courier Newn@Q!@MbX?MbX?%1tx1Courier New(\u@Q!@MbX?MbX?%dx1Courier New^I +@Q!@MbX?MbX?%02c$x1Courier NewK7A`@Q!@MbX?MbX?if [Claim Detail - Anesthesia Minutes] = "0" then [Claim Detail - Units] else [Claim Detail - Anesthesia Minutes] endif x1Courier New^I @h|?u!@Mb?㥛 ?x1Courier Newn@h|?u!@5^I ?㥛 ?@x1Courier Newn@Q!@/$?MbX?dTimes New Romann@Q!@㥛 ?MbX?x1Courier New?㥛 p"@MbX?MbX?%02mx1Courier Newx&1?㥛 p"@\(\?MbX?%02Dx1Courier NewS?㥛 p"@\(\?MbX?%Yx1Courier Newy&1?㥛 p"@MbX?MbX?%02mx1Courier New?㥛 p"@\(\?MbX?%02Dx1Courier New?㥛 p"@x&1?MbX?%Yx1Courier New/$@㥛 p"@?MbX?x1Courier New^I +@㥛 p"@?MbX?x1Courier Newn @㥛 p"@?MbX?x1Courier New^I +@㥛 p"@MbX?MbX?Zx1Courier NewnJ@㥛 p"@MbX?MbX?[x1Courier New@㥛 p"@MbX?MbX?x1Courier Newn@㥛 p"@MbX?MbX?%1tx1Courier New(\u@㥛 p"@MbX?MbX?%dx1Courier New^I +@㥛 p"@MbX?MbX?%02c$x1Courier NewK7A`@㥛 p"@x&1?MbX?if [Claim Detail - Anesthesia Minutes] = "0" then [Claim Detail - Units] else [Claim Detail - Anesthesia Minutes] endif x1Courier New^I @L7A`%"@Mb?㥛 ?x1Courier Newn@L7A`%"@5^I ?㥛 ?@x1Courier Newn@㥛 p"@/$?MbX?dTimes New Romann@㥛 p"@㥛 ?MbX?cx1Courier New^I @/$#@y&1?Mb?%dcx1Courier NewK7A@/$#@Q?Mb?%02cdx1Courier New^I @/$#@y&1?Mb?%ddx1Courier NewK7A@/$#@Q?Mb?%02cex1Courier NewK7A`@/$#@?Mb?%dex1Courier New@/$#@x&1?Mb?%02c x1Courier Newy&1?v#@^I +?Mb?if [Provider Tax ID] <> "" then [Provider Tax ID] else [Provider Social Security Number] endifx1Courier New^I +?/$#@Mb?Mb?if [Provider Tax ID] = "" and [Provider Social Security Number] <> "" then "X" endifx1Courier NewtV@/$#@Mb?Mb?if [Provider Tax ID] <> "" then "X" endif x1Courier New/$@/$#@y&1?Mb?Ux1Courier New@/$#@㥛 ?Mb?Vx1Courier New@/$#@㥛 ?Mb? x1Courier NewMbX?@$@n@Mb?tx1Courier New^I +?v$@?Mb?%02m %02D %Yx1Courier Newn@L7A`e$@/$@K7A`?[Practice City] " " [Practice State] " " [Practice Zip Code]x1Courier Newn@㥛 p#@y&1?K7A`?/x1Courier NewE@Dl?@MbX?0x1Courier NewE@S?@y&1?@x1Courier New"~@E?^I +@Mb?4x1Courier NewS??/$@Mb?DashOnly [Patient Last Name] NoStrip ", " NoStripEnd [Patient First Name] NoStrip ", " NoStripEnd [Patient Middle Initial] DashOnlyEndx1Courier New"~j @?MbX?㥛 ?%02mx1Courier NewE @?MbX?㥛 ?%02Dx1Courier NewtV@?y&1?㥛 ?%YEx1Courier New9v@?㥛 ?Mb?Fx1Courier New9v@?q= ףp?Mb?4x1Courier New"~@?n@Mb?if [Primary Insurance Type] = "G" and [Patient Chart Number] = [Secondary Insured Chart Number] then "SAME" elseif [Primary Insurance Type] = "G" and [Patient Chart Number] <> [Secondary Insured Chart Number] then DashOnly [Secondary Insured Last Name] NoStrip ", " NoStripEnd [Secondary Insured First Name] NoStrip ", " NoStripEnd [Secondary Insured Middle Initial] DashOnlyEnd endifx1Courier NewS?Dl@^I +@Mb?nx1Courier New @E@K7A`?Mb?ox1Courier New/$@E@㥛 ?Mb?px1Courier Newh|?@E@K7A`?Mb?qx1Courier New9v@Dl@Mb?Mb?x1Courier NewS?"~j@/$@Mb?x1Courier NewE@"~j@x&1?Mb?x1Courier NewDl @"~j@㥛 ?Mb?if [Patient Marital Status] = "S" then "X" endifx1Courier Newh|?5@"~j@㥛 ?Mb?if [Patient Marital Status] = "M" then "X" endifx1Courier New9v@"~j@㥛 ?Mb?if [Patient Marital Status] <> "S" and [Patient Marital Status] <> "M" then "X" endifx1Courier NewS?@ףp= ?Mb?x1Courier NewDl @@㥛 ?Mb?if [Patient Employment Status] = "F" or [Patient Employment Status] = "P" then "X" endifx1Courier Newh|?5@@㥛 ?Mb?if [Patient Student Status] = "F" then "X" endifx1Courier New9v@@㥛 ?Mb?if [Patient Student Status] = "P" then "X" endif8x1Courier NewS?"~j @@Mb?if [Secondary Insurance Type] = "D" and [Patient Chart Number] <> [Secondary Insured Chart Number] then DashOnly [Secondary Insured Last Name] NoStrip ", " NoStripEnd [Secondary Insured First Name] NoStrip ", " NoStripEnd [Secondary Insured Middle Initial] DashOnlyEnd elseif [Secondary Insurance Type] = "D" and [Patient Chart Number] = [Secondary Insured Chart Number] then "SAME" endifGx1Courier NewDl @"~j @㥛 ?Mb?Hx1Courier Newh|?5@"~j @q= ףp?Mb?>x1Courier New@"~j @㥛 ?Mb?if [Primary Insurance Type] = "G" and [Patient Chart Number] <> [Secondary Insured Chart Number] and [Secondary Insured Sex] = "M" then "X" endif>x1Courier NewE@"~j @㥛 ?Mb?if [Primary Insurance Type] = "G" and [Patient Chart Number] <> [Secondary Insured Chart Number] and [Secondary Insured Sex] = "F" then "X" endifAx1Courier Newsh|?@@㥛 ?Mb?if [Secondary Insurance Type] = "D" and [Patient Chart Number] <> [Secondary Insured Chart Number] and [Secondary Insured Sex] = "M" then "X" endifAx1Courier NewE@@㥛 ?Mb?if [Secondary Insurance Type] = "D" and [Patient Chart Number] <> [Secondary Insured Chart Number] and [Secondary Insured Sex] = "F" then "X" endifx1Courier NewDl @@㥛 ?Mb?if [Box - Auto Accident] = "X" then "X" endifx1Courier Newh|?5@@㥛 ?Mb?if [Box - Auto Accident] <> "X" then "X" endifx1Courier NewE@@?Mb?if [Box - Auto Accident] = "X" then [Accident State] endifx1Courier NewDl @E@㥛 ?Mb?if [Box - Other Accident] = "X" then "X" endifx1Courier Newh|?5@E@㥛 ?Mb?if [Box - Other Accident] <> "X" then "X" endifx1Courier NewˡE?h|?@n@Mb?tx1Courier New"~j@h|?@?Mb?%02m %02D %Yx1Courier New"~j@h|?@@Mb?x1Courier New?h|?5@MbX?㥛 ?%02mx1Courier New-?h|?5@MbX?㥛 ?%02Dx1Courier NewS?h|?5@MbX?㥛 ?%Yx1Courier New"~j@h|?5@MbX?㥛 ?%02mx1Courier New"~@h|?5@MbX?㥛 ?%02Dx1Courier Newh|?5@h|?5@?㥛 ?%Yx1Courier New"~j@h|?5@MbX?㥛 ?%02mx1Courier Newh|?@h|?5@MbX?㥛 ?%02Dx1Courier New"~@h|?5@x&1?㥛 ?%Yx1Courier New@h|?5@MbX?㥛 ?%02mx1Courier Newh|?5@h|?5@MbX?㥛 ?%02Dx1Courier New"~j@h|?5@y&1?㥛 ?%Yx1Courier NewDl @"~@tV?Mb?Cx1Courier NewDl @@ףp= ?Mb?x1Courier New"~j@@MbX?㥛 ?%02mx1Courier Newh|?@@MbX?㥛 ?%02Dx1Courier New"~@@x&1?㥛 ?%Yx1Courier New@@MbX?㥛 ?%02mx1Courier Newh|?5@@MbX?㥛 ?%02Dx1Courier New"~j@@y&1?㥛 ?%Yvx1Courier NewS?h|?@@?Ox1Courier New9v@E@㥛 ?㥛 ?Px1Courier New9v@E@㥛 ?㥛 ?x1Courier New9v@E@Gz?Mb?%dx1Courier Newh|?5@E@MbX?Mb?%02cx1Courier New"~@@^I +@Mb?if [CLIA Number] = "" then [Primary Insurance Prior Authorization] else "CLIA " [CLIA Number] endifwx1Courier NewˡE?h|?5@/$?Mb?yx1Courier NewˡE?@/$?Mb?{x1Courier NewE @h|?5@/$?Mb?}x1Courier NewE @@/$?Mb?x1Courier Newn@$@/$@K7A`?[Practice Address Line 1] [Practice Address Line 2]x1Courier New"~?@ףp= ?Mb?Bx1Courier NewDl@v$@?㥛 ?x1Courier NewE @v$@?㥛 ?gx1Courier Newsh|? @v$@MbX?㥛 ? x1Courier NewnJ@v$@MbX?㥛 ?:x1Courier New/$@v$@?㥛 ?x1Courier NewS?"~j@@K7A`?if [Referring Physician Last Name] <> "" then DashOnly [Referring Physician Last Name] NoStrip " " NoStripEnd [Referring Physician First Name] NoStrip " " NoStripEnd [Referring Physician Middle Initial] DashOnlyEnd endifx1Courier NewDl@"~#@tV@K7A`?DashOnly [Facility Name] DashOnlyEndx1Courier Newn@L7A`#@/$@K7A`?DashOnly [Practice Name] DashOnlyEndx1Courier NewDl@vZ$@tV@K7A`?[Facility City] " " [Facility State] " " [Facility Zip Code]x1Courier NewDl@$@tV@K7A`?[Facility Address Line 1] " " [Facility Address Line 2]2x1Courier New"~@@5^I ?Mb?if [Primary Insurance Type] = "G" and [Patient Chart Number] <> [Secondary Insured Chart Number] then [Secondary Insured Phone] endif5x1Courier New"~@@5^I ?Mb?if [Primary Insurance Type] = "G" and [Patient Chart Number] <> [Secondary Insured Chart Number] then [Secondary Insured Zip Code] endif2x1Courier NewET@"~j@x&1?Mb?if [Primary Insurance Type] = "G" and [Patient Chart Number] <> [Secondary Insured Chart Number] then [Secondary Insured State] endif4x1Courier New"~@Dl@/$@Mb?if [Primary Insurance Type] = "G" and [Patient Chart Number] <> [Secondary Insured Chart Number] then [Secondary Insured Address] endif1x1Courier New"~@"~j@@Mb?if [Primary Insurance Type] = "G" and [Patient Chart Number] <> [Secondary Insured Chart Number] then [Secondary Insured City] endif x1Courier NewS?"~j @@Mb?if [Secondary Insurance Type] = "D" then "MEDIGAP " + [Secondary Insurance Policy Number] endif;x1Courier New?@jt?㥛 ?if [Secondary Insurance Type] = "D" and [Patient Chart Number] <> [Secondary Insured Chart Number] then [Secondary Insured Birth Date] endif%Y=x1Courier NewS?@MbX?㥛 ?if [Secondary Insurance Type] = "D" and [Patient Chart Number] <> [Secondary Insured Chart Number] then [Secondary Insured Birth Date] endif%02m=x1Courier New-?@MbX?㥛 ?if [Secondary Insurance Type] = "D" and [Patient Chart Number] <> [Secondary Insured Chart Number] then [Secondary Insured Birth Date] endif%02Dx1Courier NewS?E@@Mb?if [Secondary Insurance Type] = "D" and [Secondary Insurance Medigap ID] = "" then [Secondary Insurance Address Line 1] + " " + [Secondary Insurance Address Line 2] + " " + [Secondary Insurance City] + " " + [Secondary Insurance State] + " " + [Secondary Insurance Zip Code] endifx1Courier NewS?h|?5@@Mb?if [Secondary Insurance Medigap ID] <> "" and [Secondary Insurance Type] = "D" then [Secondary Insurance Medigap ID] elseif [Secondary Insurance Medigap ID] = "" and [Secondary Insurance Type] = "D" then [Secondary Insurance Name] endifx1Courier Newsh|? @h|?5@/$?Mb?if [Secondary Insurance Type] = "E" then "MCD " + [Secondary Insurance ID Number] endifx1Courier New"~@"~j @/$@Mb?if [Primary Insurance Type] = "G" and [Secondary Insurance Type] <> "D" and [Secondary Insurance Type] <> "E" and [Secondary Insurance Type] <> "F" then [Secondary Insurance Policy Number] elseif [Primary Insurance Type] = "C" then "NONE" endif9x1Courier New@"~j @㥛 ?㥛 ?if [Primary Insurance Type] = "G" and [Patient Chart Number] <> [Secondary Insured Chart Number] then [Secondary Insured Birth Date] endif%Y;x1Courier NewET@"~j @x&1?㥛 ?if [Primary Insurance Type] = "G" and [Patient Chart Number] <> [Secondary Insured Chart Number] then [Secondary Insured Birth Date] endif%02D;x1Courier New9v@"~j @x&1?㥛 ?if [Primary Insurance Type] = "G" and [Patient Chart Number] <> [Secondary Insured Chart Number] then [Secondary Insured Birth Date] endif%02mix1Courier New"~@E@@Mb?if [Primary Insurance Type] = "G" and [Secondary Insurance Type] <> "D" and [Secondary Insurance Type] <> "E" and [Secondary Insurance Type] <> "F" and [Patient Employment Status] <> "R" and [Patient Chart Number] <> [Secondary Insured Chart Number] then [Secondary Insured Employer Name] elseif [Patient Chart Number] = [Secondary Insured Chart Number] and [Patient Employment Status] = "R" then "RETIRED " + [Return to Work Date] endifx1Courier New"~@E@@Mb?if [Primary Insurance Type] = "G" and [Secondary Insurance Type] <> "D" and [Secondary Insurance Type] <> "E" and [Secondary Insurance Type] <> "F" and [Secondary Insurance Medigap ID] <> "" then [Secondary Insurance Medigap ID] elseif [Primary Insurance Type] = "G" and [Secondary Insurance Type] <> "D" and [Secondary Insurance Type] <> "E" and [Secondary Insurance Type] <> "F" and [Secondary Insurance Medigap ID] = "" then [Secondary Insurance Name] endif4x1Courier New9v@v$@^I +?K7A`?if [Provider Group National Provider ID] <> "" then [Provider Group National Provider ID] else [Provider National Provider ID] endif x1Courier New/$ @K7A@MbX?MbX?if [Referring Physician Insurance Code 1] <> "" then "1G" else "" endif