????!@&@Z"ArialdTimes New Roman(\@n@jt?K7A`?Z"Arialjt?n@@MbX?MbX?%02mZ"ArialMbX?n@@\(\?MbX?%02DZ"Arial?n@@㥛 ?MbX?%YZ"Arial/$?n@@MbX?MbX?%02mZ"Arial5^I ?n@@\(\?MbX?%02DZ"Arialףp= ?n@@㥛 ?MbX?%YZ"Arial@n@@?MbX?Z"Arial/$@n@@K7A`?㥛 ?Z"Arial/$@n@@?MbX?Z"Arial^I + @n@@?MbX?Z"Arial/$@n@@MbX?MbX?ZZ"Arial@n@@MbX?MbX?[Z"Arial^I @n@@MbX?MbX?Z"Arial@n@@MbX?MbX?Z"Arial/$@n@@MbX?MbX?%dZ"ArialK7A`@n@@MbX?MbX?%02c$Z"Arial/$@n@@x&1?MbX?if [Claim Detail - Anesthesia Minutes] = "0" then [Claim Detail - Units] else [Claim Detail - Anesthesia Minutes] endifZ"Arial/$@n@@K7A`?㥛 ? Z"ArialK7A@/$@K7A`?㥛 ?Z"Arial@/$@5^I ?㥛 ?@Z"Arial@n@@jt?㥛 ?dTimes New RomanK7A@n@@㥛 ?K7A`?Z"Arialjt?/$@MbX?MbX?%02mZ"ArialMbX?/$@\(\?MbX?%02DZ"Arial?/$@㥛 ?MbX?%YZ"Arial/$?/$@MbX?MbX?%02mZ"Arial5^I ?/$@\(\?MbX?%02DZ"Arialףp= ?/$@㥛 ?MbX?%YZ"Arial@/$@?MbX?Z"Arial/$@/$@K7A`?㥛 ?Z"Arial/$@/$@?MbX?Z"Arial^I + @/$@?MbX?Z"Arial/$@/$@MbX?MbX?ZZ"Arial@/$@MbX?MbX?[Z"Arial^I @/$@MbX?MbX?Z"Arial@/$@MbX?MbX?Z"Arial/$@/$@MbX?MbX?%dZ"ArialK7A`@/$@MbX?MbX?%02c$Z"Arial/$@/$@MbX?MbX?if [Claim Detail - Anesthesia Minutes] = "0" then [Claim Detail - Units] else [Claim Detail - Anesthesia Minutes] endifZ"Arial/$@/$@K7A`?㥛 ? Z"ArialK7A@ ףp= @Mb?㥛 ?Z"Arial@/$@5^I ?㥛 ?@Z"Arial@^I @tV?㥛 ?dTimes New RomanK7A@/$@㥛 ?K7A`?Z"Arialjt?㥛 p @MbX?MbX?%02mZ"ArialMbX?㥛 p @\(\?MbX?%02DZ"Arial?㥛 p @㥛 ?MbX?%YZ"Arial/$?㥛 p @MbX?MbX?%02mZ"Arial5^I ?㥛 p @\(\?MbX?%02DZ"Arialףp= ?㥛 p @㥛 ?MbX?%YZ"Arial@㥛 p @?MbX?Z"Arial/$@㥛 p @K7A`?㥛 ?Z"Arial/$@㥛 p @?MbX?Z"Arial^I + @㥛 p @?MbX?Z"Arial/$@㥛 p @MbX?MbX?ZZ"Arial@㥛 p @MbX?MbX?[Z"Arial^I @㥛 p @MbX?MbX?Z"Arial@㥛 p @MbX?MbX?Z"Arial/$@㥛 p @MbX?MbX?%dZ"ArialK7A`@㥛 p @MbX?MbX?%02c$Z"Arial/$@㥛 p @Mb?MbX?if [Claim Detail - Anesthesia Minutes] = "0" then [Claim Detail - Units] else [Claim Detail - Anesthesia Minutes] endifZ"Arial/$@㥛 p @K7A`?㥛 ? Z"ArialK7A@L7A`% @Mb?㥛 ?Z"Arial@L7A`% @5^I ?㥛 ?@Z"Arial@Q @tV?㥛 ?dTimes New RomanK7A@㥛 p @㥛 ?K7A`?Z"Arialjt?L7A`%!@MbX?MbX?%02mZ"ArialMbX?L7A`%!@\(\?MbX?%02DZ"Arial?L7A`%!@㥛 ?MbX?%YZ"Arial/$?L7A`%!@MbX?MbX?%02mZ"Arial5^I ?L7A`%!@\(\?MbX?%02DZ"Arialףp= ?L7A`%!@㥛 ?MbX?%YZ"Arial@L7A`%!@?MbX?Z"Arial/$@L7A`%!@K7A`?㥛 ?Z"Arial/$@L7A`%!@?MbX?Z"Arial^I + @L7A`%!@?MbX?Z"Arial/$@L7A`%!@MbX?MbX?ZZ"Arial@L7A`%!@MbX?MbX?[Z"Arial^I @L7A`%!@MbX?MbX?Z"Arial@L7A`%!@MbX?MbX?Z"Arial/$@L7A`%!@MbX?MbX?%dZ"ArialK7A`@L7A`%!@MbX?MbX?%02c$Z"Arial/$@L7A`%!@x&1?MbX?if [Claim Detail - Anesthesia Minutes] = "0" then [Claim Detail - Units] else [Claim Detail - Anesthesia Minutes] endifZ"Arial/$@L7A`%!@K7A`?㥛 ? Z"ArialK7A@L7A` @Mb?㥛 ?Z"Arial@L7A` @5^I ?㥛 ?@Z"Arial@{G:!@tV?㥛 ?dTimes New RomanK7A@L7A`%!@㥛 ?K7A`?Z"Arialjt?n!@MbX?MbX?%02mZ"ArialMbX?n!@\(\?MbX?%02DZ"Arial?n!@㥛 ?MbX?%YZ"Arial/$?n!@MbX?MbX?%02mZ"Arial5^I ?n!@\(\?MbX?%02DZ"Arialףp= ?n!@㥛 ?MbX?%YZ"Arial@n!@?MbX?Z"Arial/$@n!@K7A`?㥛 ?Z"Arial/$@n!@?MbX?Z"Arial^I + @n!@?MbX?Z"Arial/$@n!@MbX?MbX?ZZ"Arial@n!@MbX?MbX?[Z"Arial^I @n!@MbX?MbX?Z"Arial@n!@MbX?MbX?Z"Arial/$@n!@MbX?MbX?%dZ"ArialK7A`@n!@MbX?MbX?%02c$Z"Arial/$@n!@MbX?MbX?if [Claim Detail - Anesthesia Minutes] = "0" then [Claim Detail - Units] else [Claim Detail - Anesthesia Minutes] endifZ"Arial/$@n!@K7A`?㥛 ? Z"ArialK7A@n!@Mb?㥛 ?Z"Arial@n!@5^I ?㥛 ?@Z"Arial@K7A!@tV?㥛 ?dTimes New RomanK7A@n!@㥛 ?K7A`?Z"Arialjt?{Gz"@MbX?MbX?%02mZ"ArialMbX?{Gz"@\(\?MbX?%02DZ"Arial?{Gz"@㥛 ?MbX?%YZ"Arial/$?{Gz"@MbX?MbX?%02mZ"Arial5^I ?{Gz"@\(\?MbX?%02DZ"Arialףp= ?{Gz"@㥛 ?MbX?%YZ"Arial@{Gz"@?MbX?Z"Arial/$@{Gz"@K7A`?㥛 ?Z"Arial/$@{Gz"@?MbX?Z"Arial^I + @{Gz"@?MbX?Z"Arial/$@{Gz"@MbX?MbX?ZZ"Arial@{Gz"@MbX?MbX?[Z"Arial^I @{Gz"@MbX?MbX?Z"Arial@{Gz"@MbX?MbX?Z"Arial/$@{Gz"@MbX?MbX?%dZ"ArialK7A`@{Gz"@MbX?MbX?%02c$Z"Arial/$@{Gz"@x&1?MbX?if [Claim Detail - Anesthesia Minutes] = "0" then [Claim Detail - Units] else [Claim Detail - Anesthesia Minutes] endifZ"Arial/$@{Gz"@K7A`?㥛 ? Z"ArialK7A@㥛 0"@Mb?㥛 ?Z"Arial@{G:"@5^I ?㥛 ?@Z"Arial@n"@tV?㥛 ?dTimes New RomanK7A@{Gz"@㥛 ?K7A`?cZ"Arialn@/$#@y&1?Mb?%dcZ"Arial@/$#@Q?Mb?%02cdZ"Arialn@/$#@y&1?MbX?%ddZ"Arial(\@/$#@Q?Mb?%02ceZ"Arial(\u@/$#@?Mb?%deZ"Arial/$@/$#@x&1?Mb?%02c Z"Arial\(\?/$#@^I +?Mb?if [Provider Tax ID] <> "" then [Provider Tax ID] else [Provider Social Security Number] endifZ"Arialףp= ?/$#@Mb?K7A`?if [Provider Tax ID] = "" and [Provider Social Security Number] <> "" then "X" endifZ"Arial/$@/$#@Mb?K7A`?if [Provider Tax ID] <> "" then "X" endif Z"ArialQ@/$#@y&1?Mb?UZ"Arial^I +@/$#@㥛 ?㥛 ?VZ"Arial^I +@/$#@㥛 ?㥛 ? Z"Arial㥛 ?nJ$@tV?Mb?tZ"Arial?K7A$@?Mb?%02m %02D %YZ"Arial@/$U$@Q@x&1?[Practice City] " " [Practice State] " " [Practice Zip Code]Z"ArialK7A`@{Gz#@5^I ?K7A`?/Z"Arial@tV?@MbX?0Z"Arial@Gz?@y&1?fZ"Arialy&1?^I +??K7A`?gZ"Arial?^I +???hZ"Arial^I +?^I +???iZ"Arialn@^I +???mZ"ArialtV @^I +???jZ"ArialK7A`@^I +???kZ"Arialn@^I +???@Z"Arial@^I +?^I +@Mb?4Z"Arialjt?tV?/$@Mb?DashOnly [Patient Last Name] NoStrip ", " NoStripEnd [Patient First Name] NoStrip ", " NoStripEnd [Patient Middle Initial] DashOnlyEndZ"Arial/$ @tV?MbX?㥛 ?%02mZ"Arial @tV?MbX?㥛 ?%02DZ"ArialtV@tV?y&1?㥛 ?%YEZ"Arial^I @tV?㥛 ?Mb?FZ"Arial^I @tV?q= ףp?Mb?~Z"Arial@tV?n@Mb?if [Primary Insured Last Name] <> "" then DashOnly [Primary Insured Last Name] NoStrip ", " NoStripEnd [Primary Insured First Name] NoStrip ", " NoStripEnd [Primary Insured Middle Initial] DashOnlyEnd endifZ"Arialjt?n@^I +@Mb?nZ"Arial @Q@K7A`?Mb?oZ"Arial/$@Q@㥛 ?Mb?pZ"Arial^I @Q@K7A`?Mb?qZ"Arial^I @Q@Mb?Mb?Z"Arial@n@^I +@Mb?Z"Arialjt?tV@/$@Mb?Z"ArialQ@tV@x&1?Mb?Z"Arialn @/$@㥛 ?Mb?if [Patient Marital Status] = "S" then "X" endifZ"ArialnJ@/$@㥛 ?Mb?if [Patient Marital Status] = "M" then "X" endifZ"Arial^I @/$@㥛 ?Mb?if [Patient Marital Status] <> "S" and [Patient Marital Status] <> "M" then "X" endifLZ"Arial@tV@@Mb?MZ"Arial@tV@x&1?Mb?Z"Arialy&1?^I +@ףp= ?Mb?Z"Arialn @^I +@㥛 ?Mb?if [Patient Employment Status] = "F" or [Patient Employment Status] = "P" then "X" endifZ"ArialnJ@^I +@㥛 ?Mb?if [Patient Student Status] = "F" then "X" endifZ"Arial^I @^I +@㥛 ?Mb?if [Patient Student Status] = "P" then "X" endifNZ"Arial@^I +@tV?Mb?Z"Arialy&1?/$ @Q@Mb?if [Secondary Insured Last Name] <> "" then DashOnly [Secondary Insured Last Name] NoStrip ", " NoStripEnd [Secondary Insured First Name] NoStrip ", " NoStripEnd [Secondary Insured Middle Initial] DashOnlyEnd endif?Z"Arial@/$ @/$@Mb?Z"Arialy&1?/$ @@Mb?GZ"Arialn @/$ @㥛 ?Mb?HZ"ArialnJ@/$ @q= ףp?Mb?PZ"Arial^I +@/$ @MbX?㥛 ?%02mPZ"ArialK7A`@/$ @MbX?㥛 ?%02DPZ"Arial/$@/$ @jt?㥛 ?%YZ"Arial/$@/$ @㥛 ?Mb?if [Primary Insured Sex] = "M" then "X" endifZ"ArialK7A@/$ @㥛 ?Mb?if [Primary Insured Sex] = "F" then "X" endifZ"Arialx&1?^I +@MbX?㥛 ?%02mZ"Arial5^I ?^I +@MbX?㥛 ?%02DZ"Arial?^I +@jt?㥛 ?%YZ"ArialtV@tV@㥛 ?Mb?if [Secondary Insured Sex] = "M" then "X" endifZ"Arial@tV@㥛 ?Mb?if [Secondary Insured Sex] = "F" then "X" endifZ"Arialn @^I +@㥛 ?Mb?if [Box - Auto Accident] = "X" then "X" endifZ"ArialnJ@^I +@㥛 ?Mb?if [Box - Auto Accident] <> "X" then "X" endifZ"ArialK7A@^I +@?Mb?if [Box - Auto Accident] = "X" then [Accident State] endifSZ"Arial@Q@@Mb?Z"Arialy&1?K7A@@Mb?Z"Arialn @K7A@㥛 ?Mb?if [Box - Other Accident] = "X" then "X" endifZ"ArialnJ@K7A@㥛 ?Mb?if [Box - Other Accident] <> "X" then "X" endif/Z"Arial@K7A@@Mb?oZ"Arialy&1?^I +@/$@Mb?Z"Arial/$@n@@㥛 ?Mb?if [Secondary Insurance Indicator] = "Y" then "X" endifZ"Arial/$@n@@㥛 ?Mb?if [Secondary Insurance Indicator] <> "Y" then "X" endifZ"ArialMbX?n@n@Mb?tZ"Arial/$@n@?Mb?%02m %02D %YZ"Arial@n@@Mb?Z"ArialMbX?nJ@MbX?㥛 ?%02mZ"Arial5^I ?nJ@MbX?㥛 ?%02DZ"ArialGz?nJ@MbX?㥛 ?%YZ"Arial/$@nJ@MbX?㥛 ?%02mZ"Arial@nJ@MbX?㥛 ?%02DZ"Arialn@@nJ@?㥛 ?%YZ"Arial@nJ@MbX?㥛 ?%02mZ"Arialn@nJ@MbX?㥛 ?%02DZ"Arial@nJ@x&1?㥛 ?%YZ"Arial/$@nJ@MbX?㥛 ?%02mZ"ArialnJ@nJ@MbX?㥛 ?%02DZ"Arial@nJ@y&1?㥛 ?%YZ"Arialn @ ףp= @tV?Mb?CZ"Arialn @^I @ףp= ?Mb?Z"Arial@/$@MbX?㥛 ?%02mZ"Arialn@/$@MbX?㥛 ?%02DZ"Arial@/$@x&1?㥛 ?%YZ"Arial/$@/$@MbX?㥛 ?%02mZ"ArialnJ@/$@MbX?㥛 ?%02DZ"Arial@/$@y&1?㥛 ?%YvZ"Arialy&1?^I @@?OZ"Arial^I @K7A@㥛 ?㥛 ?PZ"Arial^I @K7A@㥛 ?㥛 ?Z"Arial@n@@^I +?㥛 ?if [Primary Insurance Type] = "E" then [Medicaid Resubmission Number] endifZ"Arial/$@n@@?㥛 ?if [Primary Insurance Type] = "E" then [Medicaid Original Reference Number] endifZ"Arial@/$@^I +@Mb?if [CLIA Number] = "" then [Primary Insurance Prior Authorization] else "CLIA " [CLIA Number] endifwZ"ArialMbX?n@@/$?Mb?yZ"ArialMbX?/$@/$?Mb?{Z"Arial @n@@/$?Mb?}Z"Arial @/$@/$?Mb?Z"Arial@{G#@tV@Mb?[Practice Address Line 1] [Practice Address Line 2]Z"Arial?^I +@jt?Mb?OZ"Arial@^I +@5^I ?Mb?BZ"Arial@/$$@?㥛 ?Z"Arial @/$$@?㥛 ?gZ"Arial/$ @/$$@MbX?㥛 ? Z"Arial(\u@/$$@MbX?㥛 ?:Z"Arialn@@/$$@?㥛 ?Z"Arialy&1?(\u@@K7A`?if [Referring Physician Last Name] <> "" then DashOnly [Referring Physician Last Name] NoStrip " " NoStripEnd [Referring Physician First Name] NoStrip " " NoStripEnd [Referring Physician Middle Initial] DashOnlyEnd endifZ"Arial^I +@㥛 #@@K7A`?DashOnly [Facility Name] DashOnlyEndZ"Arial@L7A`#@/$@K7A`?DashOnly [Practice Name] DashOnlyEndZ"Arial@K7A`$@tV@K7A`?[Facility City] " " [Facility State] " " [Facility Zip Code]Z"Arial@n $@/$@K7A`?[Facility Address Line 1] " " [Facility Address Line 2]2Z"Arial(\@/$$@/$?K7A`?if [Provider Group National Provider ID] <> "" then [Provider Group National Provider ID] else [Provider National Provider ID] endifZ"ArialK7A@K7A@MbX?Mb?%dZ"ArialK7A@K7A@y&1?Mb?%02cZ"Arialn @/$@x&1?Mb?if [Referring Physician Insurance Code 1] <> "" then "1G" else "" endif