Patient Form Pull Fields

Paper Form Pull Fields - PatientPatient pull fields are to be used with the 'Patient' Form Type and will pull data onto paper form templates. Patient pull field categories include:

• Account

• Appointment

• Custom Fields

• Diagnosis

• Family Recall

• Incident

• Miscellaneous

• Office

• Patient

• Patient Allergies

• Primary Guarantor

• Primary Insurance

• Primary Procedure Types

• Primary Referral

• Provider

• Secondary Guarantor

• Secondary Insurance

• Secondary Procedure Types

• Secondary Referral

• Tertiary Insurance

• Tertiary Procedure Types

• Tertiary Referral

• Treatments

Account

• Account Balance 120 Days: This will display the total past due Account Balance for any charges that are between 121 and 150 days old as determined by the selected charge'(s) procedure date.

• Account Balance 120 Plus Days: This will display the total past due Account Balance for any open charges that are over 120 days old as determined by the selected charge'(s) procedure date.

• Account Balance 150 Plus Days: This will display the total past due Account Balance for any open charges that are over 150 days old as determined by the selected charge'(s) procedure date.

• Account Balance 30 Days: This will display the total past due Account Balance for any open charges that are between 31 and 60 days old as determined by the selected charge'(s) procedure date.

• Account Balance 60 Days: This will display the total past due Account Balance for any open charges that are between 61 and 90 days old as determined by the selected charge'(s) procedure date.

• Account Balance 90 Days: This will display the total past due Account Balance for any open charges that are between 91 and 120 days old as determined by the selected charge'(s) procedure date.

• Account Balance Current: This will display the total Account Balance for any open charges that are between 1 and 30 days old as determined by the selected charge'(s) procedure date.

• Account Balance Days Overdue: This will display the age of the oldest open charge on the account.

• Account Balance Insurance Portion: This will display the full balance for the account's Insurance Portion.

• Account Balance Patient Portion: This will display the full balance for the account's Patient Portion.

• Account Balance Total: This will display the total Account Balance (Insurance + Patient Portions).

• Account Balance Total With Credit: This will display the total Account Balance less the Unapplied amount.
  [Note: This total will display as a negative if the credit balance is greater than the total account balance.]

• Account Patient - Unapplied: This will display the total Patient Portion less the Unapplied amount.
  [Note: This total will display as a negative if the Unapplied amount is greater than the total Patient Portion.]

• Account Patient Portion 120 Days: This will display the total past due Patient Portion balance for any open charges that are between 121 and 150 days old as determined by the selected charge'(s) procedure date.

• Account Patient Portion 120 Plus Days: This will display the total past due Patient Portion balance for any open charges that are over 120 days old as determined by the selected charge'(s) procedure date.

• Account Patient Portion 150 Plus Days: This will display the total past due Patient Portion balance for any open charges that are over 150 days old as determined by the selected charge'(s) procedure date.

• Account Patient Portion 30 Days: This will display the total past due Patient Portion balance for any open charges that are between 31 and 60 days old as determined by the selected charge'(s) procedure date.

• Account Patient Portion 60 Days: This will display the total past due Patient Portion balance for any open charges that are between 61 and 90 days old as determined by the selected charge'(s) procedure date.

• Account Patient Portion 90 Days: This will display the total past due Patient Portion balance for any open charges that are between 91 and 120 days old as determined by the selected charge'(s) procedure date.

• Account Patient Portion Current: This will display to total Patient Portion balance for any open charges between 1 and 30 days old as determined by the selected charge'(s) procedure date.

• Account Patient Portion Total: This will display the total Patient Portion balance.

• Account Unapplied Amount: This will display the account's total Unapplied amount.

• Accounting Alert 1: This will display the first Alert record listed in Patients > Account > Alerts. This data will pull from the 'Alert Description' field located in the selected alert's Reference.

• Accounting Alert 2: This will display the second Alert record listed in Patients > Account > Alerts. This data will pull from the 'Alert Description' field located in the selected alert's Reference.

• Accounting Alert 3: This will display the third Alert record listed in Patients > Account > Alerts. This data will pull from the 'Alert Description' field located in the selected alert's Reference.

• Accounting Alert 4: This will display the fourth Alert record listed in Patients > Account > Alerts. This data will pull from the 'Alert Description' field located in the selected alert's Reference.

• Accounting Alert 5: This will display the fifth Alert record listed in Patients > Account > Alerts. This data will pull from the 'Alert Description' field located in the selected alert's Reference.

• Accounting Alert 6: This will display the sixth Alert record listed in Patients > Account > Alerts. This data will pull from the 'Alert Description' field located in the selected alert's Reference.

• Accounting Alert 7: This will display the seventh Alert record listed in Patients > Account > Alerts. This data will pull from the 'Alert Description' field located in the selected alert's Reference.

• Accounting Alert 8: This will display the eighth Alert record listed in Patients > Account > Alerts. This data will pull from the 'Alert Description' field located in the selected alert's Reference.

• City: This will reflect the data as entered in the 'City' field located in Patients > Primary.

• Country: This will reflect the data as entered in 'Country' field located in Patients > Primary.

• Date of Birth: This will reflect the date as entered in the 'Birth Date' field located in Patients > Primary.

• Employer Address: This will display the Street Address of the first Employer record entered in the Employers table located in Patients > Primary. This data will pull from the 'Street Address' field located in the selected employer's Reference.
  [Note: If the Primary Guarantor does not have an employer entered in the Employers table this will then pull from the first Employer record entered in the Employers table located in Patients > Secondary.]

• Employer City: This will display the City of the first Employer record entered in the Employers table located in Patients > Primary. This data will pull from the 'City' filed located in the selected employer's Reference.
  [Note: If the Primary Guarantor does not have an employer entered in the Employers table this will then pull from the first Employer record entered in the Employers table located in Patients > Secondary.]

• Employer Name: This will display the Name of the first Employer record entered in the Employers table located in Patients > Primary. This data will pull from the 'Employer Name' filed located in the selected employer's Reference.
  [Note: If the Primary Guarantor does not have an employer entered in the Employers table this will then pull from the first Employer record entered in the Employers table located in Patients > Secondary.]

• Employer State: This will display the State of the first Employer record entered in the Employers table located in Patients > Primary. This data will pull from the 'State' filed located in the selected employer's Reference.
  [Note: If the Primary Guarantor does not have an employer entered in the Employers table this will then pull from the first Employer record entered in the Employers table located in Patients > Secondary.]

• Employer Suite: This will display the Suite number of the first Employer record entered in the Employers table located in Patients > Primary. This data will pull from the 'Suite' filed located in the selected employer's Reference.
  [Note: If the Primary Guarantor does not have an employer entered in the Employers table this will then pull from the first Employer record entered in the Employers table located in Patients > Secondary.]

• Employer Zip Code: This will display the Zip Code of the first Employer record entered in the Employers table located in Patients > Primary. This data will pull from the 'Zip Code' filed located in the selected employer's Reference.
  [Note: If the Primary Guarantor does not have an employer entered in the Employers table this will then pull from the first Employer record entered in the Employers table located in Patients > Secondary.]

• Financial Status: This will reflect the account's Financial Status as entered/selected from the 'Financial Status' drop down field located in Patients > Account.

• Home Phone: This will reflect the data as entered in a 'Phone' field located in Patients > Primary.
  [Note: The 'Phone' field's adjoining 'Type' popup MUST be set to "Home Phone".]

• Installment Amount: This will reflect the data as entered in the 'Installment Amount' field located in Patients > Account > Statements.

• Installment or Balance Amount: This will reflect either the Account Balance or the Installment Amount as entered in the Account tab, depending on which is less.  When displaying the account balance the unapplied amount will be taken into account.
  [Note: this total will display as a negative if the credit balance is greater than the total account balance.]

• Last Account Payment Amount (No Adj): This will display the amount of the most recent patient payment that has been posted the the Ledger.

• Last Account Payment Amount (w/ Adj): This will display the most recent patient payment or negative adjustment that has been posted to the Ledger.

• Last Account Payment Date (No Adj): This will display the date of the most recent patient payment that has been posted to the Ledger.

• Last Account Payment Date (w/ Adj): This will display the date of the most recent patient payment or negative adjustment that has been posted to the Ledger.

• Last Insurance Payment Amount: This will display the amount of the most recent insurance payment that has been posted to the Ledger.

• Last Insurance Payment Date: This will display the date of the most recent insurance payment that has been posted to the Ledger.

• Mobile Phone: This will reflect the data as entered in a 'Phone' field located in Patients > Primary.
  [Note: The 'Phone' field's adjoining 'Type' popup MUST be set to "Mobile Phone".]

• Name: This will display the Full Name of the Primary Guarantor. This data will pull from the 'First Name', 'Middle Name', and 'Last Name' fields located in Patients > Primary.
  [Note: This pull field will display the data as "first name, middle initial, last name (John X. Doe).]

• Name, First: This will display the First Name of the Primary Guarantor. This data will pull from the 'First Name' field located in Patients > Primary.

• Name, Last: This will display the Last Name of the Primary Guarantor. This data will pull from the 'Last Name (Guarantor)' field located in Patients > Primary.

• Name, Middle: This will display the Middle Name of the Primary Guarantor. This data will pull from the 'Middle Name' field located in Patients > Primary.

• Name, Prefix: This will display the Prefix of the Primary Guarantor. This data will pull from the 'Prefix' field located in Patients > Primary.

• Name, Suffix: This will display the Suffix of the Primary Guarantor. This data will pull from the 'Suffix' field located in Patients > Primary.

• Other Phone: This will reflect the data as entered in a 'Phone' field located in Patients > Primary.
  [Note: The 'Phone' field's adjoining 'Type' popup MUST be set to "Other Phone".]

• Percent Discount: This will reflect the data as entered in the 'Percent Discount (%)' field located in Patients > Account.

• Previous Account Number: This will reflect the data as entered in the 'Previous Account Number' field located in Patients > Account.

• SSN: This will reflect the data as entered in the 'Social Security' field located in Patients > Primary.

• SSN Last 4: This will reflect the last four digits of the Social Security Number as entered in the 'Social Security' field located in Patients > Primary.

• State: This will reflect the data as entered in the 'State' field located in Patients > Primary.

• Street Address: This will reflect the data as entered in the 'Street Address' field located in Patients > Primary.

• Suite: This will reflect the data as entered in 'Suite/Apt. Number' field located in Patients > Primary.

• Work Phone: This will reflect the data as entered in a 'Phone' field located in Patients > Primary.
  [Note: The 'Phone' field's adjoining 'Type' popup MUST be set to "Work Phone".]

• Zip Code: This will reflect the data as entered in the 'Zip Code' field located in Patients > Primary.

Appointment

• Appointment End: This will display either the Appointment Date or the Appointment End Time as determined by the selected appointment located in the Schedule.
  [Note: 1) Functionality dependent upon pull field formatting ("Date" or "Time"). 2) This field MUST be generated using an Appointment record located in the Schedule.]

• Appointment Length In Minutes: This will display the total Appointment Length in minutes as determined by the selected appointment located in the Schedule.
  [Note: This field MUST be generated using an Appointment record located in the Schedule.]

• Appointment Note: This will reflect the data as entered in the 'Notes' field found in the Appointment Detail Window of the selected appointment located in the Schedule.
  [Note: This field MUST be generated using an Appointment record located in the Schedule.]

• Appointment Provider First Name: This will display the First Name of the provider as selected from the 'Provider' popup found in the Appointment Detail Window of the selected appointment located in the Schedule. This data will pull from the 'First' field located in the selected provider's User Reference.
  [Note: This field MUST be generated using an Appointment record located in the Schedule.]

• Appointment Provider Form Name: This will display the Form Name data for the provider as selected from the 'Provider' popup found in the Appointment Detail Window of the selected appointment located in the Schedule. This data will pull from the 'Name Printed in Box 33 HCFA' (DDS: 'Name Printed in Box 53 of Insurance Form') field located in the selected provider's User Reference > Provider.
  [Note: This field MUST be generated using an Appointment record located in the Schedule.]

• Appointment Provider Last Name: This will display the Last Name of the provider as selected from the 'Provider' popup found in the Appointment Detail Window of the selected appointment located in the Schedule. This data will pull from the 'Last' field located in the selected provider's User Reference.
  [Note: This field MUST be generated using an Appointment record located in the Schedule.]

• Appointment Provider Middle Name: This will display the Middle Name of the provider as selected from the 'Provider' popup found in the Appointment Detail Window of the selected appointment located in the Schedule. This data will pull from the 'Middle' field located the selected provider's User Reference.
  [Note: This field MUST be generated using an Appointment record located in the Schedule.]

• Appointment Provider Professional Title: This will display the Professional Title of the provider as selected from the 'Provider' popup found in the Appointment Detail Window of the selected appointment located in the Schedule. This data will pull from the 'Professional Title' field located the selected provider's User Reference.
  [Note: This field MUST be generated using an Appointment record located in the Schedule.]

• Appointment Provider Suffix: This will display the Suffix of the provider as selected from the 'Provider' popup found in the Appointment Detail Window of the selected appointment located in the Schedule. This data will pull from the 'Suffix' field located the selected provider's User Reference.
  [Note: This field MUST be generated using an Appointment record located in the Schedule.]

• Appointment Provider User ID: This will display the User ID of the provider as selected from the 'Provider' popup found in the Appointment Detail Window of the selected appointment located in the Schedule. This data will pull from the 'User ID' field located the selected provider's User Reference.
  [Note: This field MUST be generated using an Appointment record located in the Schedule.]

• Appointment Resource Name: This will display the Resource Name for the selected appointment. This data will pull from the 'Name' field found in the resource Reference for the appointment scheduled under the selected resource located in the Schedule.
  [Note: This field MUST be generated using an Appointment record located in the Schedule.]

• Appointment Start: This will display either the Appointment Date or the Appointment Start time as determined by the selected appointment located in the Schedule.
  [Note: 1) Functionality dependent upon pull field formatting ("Date" or "Time"). 2) This field MUST be generated using an Appointment record located in the Schedule.]

• Appointment Status: This will display the Appointment Status as entered/selected from the 'Status' dropdown found in the selected appointment's Appointment Detail Window located in the Schedule.
  [Note: This field MUST be generated using an Appointment record located in the Schedule.]

• Appointment Type: This will display the Appointment Type as entered/selected from the 'Type' dropdown found in the selected appointment's Appointment Detail Window located in the Schedule.
  [Note: This field MUST be generated using an Appointment record located in the Schedule.]

Custom Fields

• Custom Optional: This field will allow the User to manually type data directly onto a paper form when attempting to print said form. This field can be ignored and the form will print without data.[Note: This field will only work if the form is printed by either dragging and dropping an appointment from the schedule onto the form in the sidebar or by secondary-clicking an appointment and selecting the 'Print Form' menu.]

• Custom Required: This field will allow the User to manually type data directly onto a paper form when attempting to print said form. This field cannot be ignored and MUST contain data before the form will be allowed to print.
  [Note: This field will only work if the form is printed by either dragging and dropping an appointment from the schedule onto the form in the sidebar or by secondary-clicking an appointment and selecting the 'Print Form' menu.]

Diagnosis

• Diagnosis 1 Code: This will display the Dx Code as found under the 'Diagnosis Code' column of the first 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 1 Description: This will display the default Description as found under the 'Description' column of the first 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 1 Notes: This will reflect the data as entered in the 'Notes' field of the first 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Patient Diagnosis 2 Code: This will display the Dx Code as found under the 'Diagnosis Code' column of the second 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 2 Description: This will display the default Description as found under the 'Description' column of the second 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 2 Notes: This will reflect the data as entered in the 'Notes' field of the second 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 3 Code: This will display the Dx Code as found under the 'Diagnosis Code' column of the third 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 3 Description: This will display the default Description as found under the 'Description' column of the third 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 3 Notes: This will reflect the data as entered in the 'Notes' field of the third 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 4 Code: This will display the Dx Code as found under the 'Diagnosis Code' column of the fourth 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 4 Description: This will display the default Description as found under the 'Description' column of the fourth 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 4 Notes: This will reflect the data as entered in the 'Notes' field of the fourth 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 5 Code: This will display the Dx Code as found under the 'Diagnosis Code' column of the fifth 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 5 Description: This will display the default Description as found under the 'Description' column of the fifth 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 5 Notes: This will reflect the data as entered in the 'Notes' field of the fifth 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 6 Code: This will display the Dx code as found under the 'Diagnosis Code' column of the sixth 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 6 Description: This will display the default Description as found under the 'Description' column of the sixth 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 6 Notes: This will reflect the data as entered in the 'Notes' field of the sixth 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 7 Code: This will display the Dx Code as found under the 'Diagnosis Code' column of the seventh 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 7 Description: This will display the default Description as found under the 'Description' column of the seventh 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 7 Notes: This will reflect the data as entered in the 'Notes' field of the seventh 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 8 Code: This will display the Dx Code as found under the 'Diagnosis Code' column of the eighth 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 8 Description: This will display the default Description as found under the 'Description' column of the eighth 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 8 Notes: This will reflect the data as entered in the 'Notes' field of the eighth 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 9 Code: This will display the Dx Code as found under the 'Diagnosis Code' column of the ninth 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 9 Description: This will display the default Description as found under the 'Description' column of the ninth 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 9 Notes: This will reflect the data as entered in the 'Notes' field of the ninth 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 10 Code: This will display the Dx Code as found under the 'Diagnosis Code' column of the tenth 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 10 Description: This will display the default Description as found under the 'Description' column of the tenth 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 10 Notes: This will reflect the data as entered in the 'Notes' field of the tenth 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 11 Code: This will display the Dx Code as found under the 'Diagnosis Code' column of the eleventh 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 11 Description: This will display the default Description as found under the 'Description' column of the eleventh 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 11 Notes: This will reflect the data as entered in the 'Notes' field of the eleventh 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 12 Code: This will display the Dx Code as found under the 'Diagnosis Code' column of the twelfth 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 12 Description: This will display the default Description as found under the 'Description' column of the twelfth 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

• Diagnosis 12 Notes: This will reflect the data as entered in the 'Notes' field of the twelfth 'Regularly Treated' Diagnosis record listed in the Problem List located in Patients > Clinical > Problem List.

Family Recall/Follow-upThe number of patients with recalls/follow-ups to display and row offset determined by Form Rules.
[Note: Default Form Rules: Max Patients - 3; Row Offset - 10.00]

• Recall Age: This will display the Age of any patient on the account that has a Recall Appointment record added to the Recalls table located in Patients > Patient > Recalls/Follow-Ups. This data is determined by the patient's 'Birth Date' field located in Patients > Patient of the respective Patient record.

• Recall Appointment: This will display the Appointment Date for any patient on the account that has a scheduled Recall Appointment record added to the Recalls table located in Patients > Patient > Recalls/Follow-Ups. This data will pull from the 'Appointment Date' column of first Recall Appointment record listed in the respective patient's Recalls table.

• Recall Appointment Note: This will display the Appointment Note for any patient on the account that has a scheduled Recall Appointment record added to the Recalls table located in Patients > Patient > Recalls/Follow-Ups. This data will display as entered in the 'Notes' field in the Appointment Window for the first scheduled Recall Appointment record listed in the respective patient's Recalls table.

• Recall Appointment Time: This will display the Appointment Start Time for any patient on the account that has a scheduled Recall Appointment record added to the Recalls table located in Patients > Patient > Recalls/Follow-Ups. This data will pull from the first Recall Appointment record listed in the respective patient's Recalls table as determined by the scheduled appointment.

• Recall Birthdate: This will display the Date of Birth for any patient on the account that has a Recall Appointment record added to the Recalls table located in Patients > Patient > Recalls/Follow-Ups. This data will pull from the 'Birth Date' field located in Patients > Patient of the respective Patient record.

• Recall Date: This will display the Recall Date for any patient on the account that has a Recall Appointment record added to the Recalls table located in Patients > Patient > Recalls/Follow-Ups. This data will pull from the 'Recall Date' column of the first Recall Appointment record listed in the respective patient's Recalls table located in Patients > Patient > Recalls/Follow-ups.

• Recall First Name: This will display the First Name of any patient on the account that has a Recall Appointment record added to the Recalls table located in Patients > Patient > Recalls/Follow-Ups. This data will pull from the 'First Name' field located in Patients > Patient of the respective Patient record.

• Recall Last Name: This will display the Last Name for any patient on the account that has a Recall Appointment record. This data will pull from the 'Last Name' field located in Patients > Patient of the respective Patient record.

• Recall Last Recall: This will display the Last Recall Date for any patient on the account that has a Recall Appointment record. This field will reflect the date as entered in the 'Last Visit' field of the first Recall Appointment record listed in the respective patient's Recalls table located in Patients > Patient > Recalls/Follow-ups.

• Recall Middle Name: This will display the Middle Name for any patient on the account that has a Recall Appointment record. This field will reflect the data as entered in the 'Middle Name' field located in Patients > Patient of the respective Patient record.

• Recall Name: This will display the First, Middle Initial, and Last Name for any patient on the account that has a Recall Appointment record. This field will reflect the data as entered in the 'First Name', 'Middle Name', and 'Last Name' fields field located in Patients > Patient of the respective Patient record.

• Recall Next Recall: This will display the Next Recall Date for any patient on the account that has a Recall Appointment. This data will reflect the date as entered/found in the 'Next Recall' field of the first Recall Appointment record listed in the respective patient's Recalls table located in Patients > Patient > Recalls/Follow-ups.

• Recall Note: This will display the Recall Note for any patient on the account that has a Recall Appointment record.  This data will pull from the 'Notes' field of the first Recall Appointment record listed in the respective patient's Recalls table located in Patients > Patient > Recalls/Follow-ups.

Incident

• Accident Date: This will reflect the date as entered in the 'Accident Date' field, located in Patients > Ledger > Incident Menu > Incident > Reason For Treatment of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Accident State: This will reflect the State as selected from the 'Accident State' popup, located in Patients > Ledger > Incident Menu > Incident > Reason For Treatment of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Admission Source Code: This will display the numeric code reflective of the selected Admission Source found in the 'Admission Source' popup located in Patients > Ledger > Incident Menu > Incident > Facility of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

  • Non-health Care Facility Point of Origin: 1

  • Clinic or Physician's Office: 2

  • Transfer from Hospital: 3

  • Transfer from SNF, INF, or ALF/Born in Hospital: 4

  • Court/Law Enforcement: 5

  • Information Not Available: 6

  • Transfer between Distinct Units of Same Hospital (Separate Claims): 7

  • Transfer from Ambulatory Surgery Center: 8

  • Transfer from Hospice Facility: 9

• Admission Type Code: This will display the numeric code reflective of the selected Admission Type found in the 'Admission Type' popup located in Patients > Ledger > Incident Menu > Incident > Facility of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

  • Emergency: 1

  • Urgent: 2

  • Elective: 3

  • Newborn: 4

  • Trauma Center: 5

• Attorney Address: This will display the Street Address of the attorney selected from the Attorney table located in Patients > Ledger > Incident Menu > Attorney of the selected patient's most recent Incident. This data will pull from the 'Street Address' field of the selected attorney's Reference of the selected patient's most recent incident.
  [Note: 1) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident. 2) This field will cause a DB error.]

• Attorney City: This will display the City of the attorney selected from the Attorney table located in Patients > Ledger > Incident Menu > Attorney of the selected patient's most recent Incident. This data will pull from the selected attorney's Reference.
  [Note: 1) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident. 2) This field will cause a DB error.]

• Attorney Deposition Date: This will reflect the date as entered in the 'Deposition Date' filed located in Patients > Ledger > Incident Menu > Attorney of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Attorney Email: This will display the Email Address of the attorney selected from the Attorney table located in Patients > Ledger > Incident Menu > Attorney of the selected patient's most recent Incident. This data will pull from the 'Email' field of the selected attorney's Reference
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Attorney Fax: This will display the Fax Number of the attorney selected from the Attorney table located in Patients > Ledger > Incident Menu > Attorney of the selected patient's most recent Incident. This data will pull from the 'Fax' field of the selected attorney's Reference.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Attorney Final Settlement Date: This will reflect the date as entered in the 'Final Settlement' field located in Patients > Ledger > Incident Menu > Attorney of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Attorney Name: This will display the Name of the attorney selected from the Attorney table located in Patients > Ledger > Incident Menu > Attorney of the selected patient's most recent Incident.This data will pull from the 'Attorney Name' field of the selected attorney's Reference.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Attorney Notes: This will reflect the data as entered in the 'Notes' field located in Patients > Ledger > Incident Menu > Attorney of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Attorney Notice Filing: This is a "True/False" pull field that will display an 'X' respective to having selected the 'Notice of Filing' checkbox located in Patients > Ledger > Incident Menu > Attorney of the selected patient's most recent Incident.
  [Note: 1) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident. 2) Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when the checkbox is selected. If formatted for "False" an 'X' will display when the checkbox is not selected.]

• Attorney Phone: This will display the Phone Number of the attorney selected from the Attorney table located in Patients > Ledger > Incident Menu > Attorney of the selected patient's most recent Incident.This data will pull from the 'Phone' field of the selected attorney's Reference.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Attorney Report Sent Date: This will reflect the date as entered in the 'Report Sent' field located in Patients > Ledger > Incident Menu > Attorney of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Attorney State: This will display the State of the attorney selected from the Attorney table located in Patients > Ledger > Incident Menu > Attorney of the selected patient's most recent Incident. This data will pull from the 'City' field of the selected attorney's Reference.
  [Note: 1) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident. 2) This field will cause a DB error.]

• Attorney Suite: This will display the Suite Number of the attorney selected from the Attorney table located in Patients > Ledger > Incident Menu > Attorney of the selected patient's most recent Incident.This data will pull from the 'Suite' field of the selected attorney's Reference.
  [Note: 1) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident. 2) This field will cause a DB error.]

• Attorney Trial Date: This will reflect the date as entered in the 'Hearing/Trial Date' field located in Patients > Ledger > Incident Menu > Attorney of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Attorney Zip Code: This will display the Zip Code of the attorney selected from the Attorney table located in Patients > Ledger > Incident Menu > Attorney of the selected patient's most recent Incident.This data will pull from the 'Zip Code' field of the attorney's selected Reference.
  [Note: 1) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident. 2) This field will cause a DB error.]

• Auto Accident Related: This is a "True/False" pull field that will display an 'X' respective to having selected "Auto Accident" from the 'Condition Related To' popup located in Patients > Ledger > Incident Menu> Incident > Reason For Treatment of the selected patient's most recent Incident.
  [Note: 1) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident. 2) Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when the checkbox is selected. If formatted for "False" an 'X' will display when the checkbox is not selected.]

• Auto Accident State: This will reflect the State as selected from the 'Accident State' popup located in Patients > Ledger > Incident Menu> Incident > Reason For Treatment of the selected patient's most recent Incident.
  [Note: "Auto Accident" MUST be selected from the 'Condition Related To' popup. 2) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Box 10D Claim Codes: This will reflect the data as entered in the 'Box 10D Claim Codes' field located in Patients > Ledger > Incident Menu > CMS Claims > Other Claim Data of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Box 11B Other Claim ID: This will reflect the data as entered in the 'Other Claim ID' field located in Patients > Ledger > Incident Menu > CMS Claims > Other Claim Data of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Box 11B Other Claim ID Qualifier: This will reflect the data as entered in the 'Box 11b Qualifier' located in Patients > Ledger > Incident Menu > CMS Claims > Other Claim Data of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Box 23B Payment Source Code: This will reflect the data as entered in the '23B Payment Source' field located in Patients > Ledger > Incident Menu > CMS Claims > Other Claim Data of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Box 25C Locator Code: This will reflect the data as entered in the 'Box 25C Locator Code' field located in Patients > Ledger > Incident Menu > CMS Claims > Other Claim Dataof the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• CMS 1500 Box 19 Data: This will reflect the data as entered in the 'Box 19 on CMS Claim Form' field located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Claim Other Date Type: This will display the numeric code reflective of the selected Date Type found in the 'Other Date Type' popup located in Patients > Ledger > Incident Menu > CMS Claims > Symptom Dates of the selected patient's most recent Incident.
  [Note: 1) "Illness" or "Last Menstrual Period" MUST be selected from the 'First Symptom Date Type' popup. 2) A valid date MUST be entered in the 'Other Date' field. 3) "Auto Accident" CANNOT be selected from the 'Condition Related To' popup located in Patients > Ledger > Incident Menu > Incident > Reason For Treatment. 4) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

  • Initial Treatment: 454

  • Latest Visit or Consultation: 304

  • Accident: 439

  • Acute Manifestation of a Chronic Condition: 453

  • Last X-ray: 455

  • Prescription: 471

  • Report Start (Assumed Care Date): 090

  • Report End (Relinquished Care Date): 091

  • First Visit or Consultation: 444

• Claim Similar Symptom Date: This will reflect the date as entered in the 'Other Date' field located in Patients > Ledger > Incident Menu > CMS Claims > Symptom Dates of the selected patient's most recent Incident.
  [Note: 1) "Illness" or "Last Menstrual Period" MUST be selected from the 'First Symptom Date Type' popup.2) "Auto Accident" CANNOT be selected from the 'Condition Related To' popup located in Patients > Ledger > Incident Menu > Incident > Reason For Treatment. 3) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Claim Symptom Date: This will reflect the date as entered in the 'First Symptom Date' Field located in Patients > Ledger > Incident Menu > CMS Claims > Symptom Dates of the selected patient's most recent Incident.
  [Note: 1) "Illness" or "Last Menstrual Period" MUST be selected from the 'First Symptom Date Type' popup. 2) Any option other than "Auto Accident" or "None" MUST be selected from the 'Condition Related To' popup located in Patients > Ledger > Incident Menu > Incident > Reason For Treatment. 3) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Claim Symptom Date Qualifier: This will display a numeric code reflective of the data selected from the 'First Symptom Date Type' popup located in Patients > Ledger > Incident Menu > CMS Claims > Symptom Dates of the selected patient's most recent Incident.
  [Note: 1)"Auto Accident" CANNOT be selected from the 'Condition Related To' popup located in Patients > Ledger > Incident Menu > Incident > Reason For Treatment. 2) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.] 

  • Routine Service: [N/A]

  • Illness: 431

  • Last Menstrual Period: 484

• Condition Related To: This will reflect the data as selected from the 'Condition Related To' popup located in Patients > Ledger > Incident Menu > Incident > Reason For Treatment of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Date Appliance Placed: This will reflect the date as entered in the 'Box 41 Date Appliance Placed' field located in Patients > Ledger > Incident Menu > ADA Claims of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Date Prior Placement: This will reflect the date as entered in the 'Box 44 Date Prior Placement' field located in Patients > Ledger > Incident Menu > ADA Claims of the selected patient's most recent Incident.
  [Note: 1) DDS Only. 2) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Effective Date: This will reflect the date as entered in the 'Effective Date' field located in Patients > Ledger > Incident Menu > Military of the selected patient's most recent Incident.
  [Note: 1) DDS Only. 2) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Employment Related: This is a "True/False" pull field that will display an 'X' respective to having selected "Employment" from the 'Condition Related To' popup located in Patients > Ledger > Incident Menu > Incident > Reason For Treatment of the selected patient's most recent Incident.
  [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when "Employment" is selected. If formatted for "False", an 'X' will display when not selected. 2) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Facility Address: This will display the Street Address of the facility added to the Facility table located in Patients > Ledger > Incident Menu > Incident > Facility of the selected patient's most recent Incident. This data will pull from the 'Street Address' field located the selected facility's Reference.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Facility City: This will display the City of the facility added to the Facility table located in Patients > Ledger > Incident Menu > Incident > Facility of the selected patient's most recent Incident. This data will pull from the 'City' field located the selected facility's Reference.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Facility Code 1: This will display the Facility Tax ID of the facility added to the Facility table located in Patients > Ledger > Incident Menu > Incident > Facility of the selected patient's most recent Incident. This data will pull from the 'Facility Tax ID' field located in the selected facility's Reference.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Facility Code 2: This will display the Secondary Facility ID of the facility added to the Facility table located in Patients > Ledger > Incident Menu > Incident > Facility of the selected patient's most recent Incident. This data will pull from the 'Secondary Facility ID' field located in the selected facility's Reference.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Facility NPI: This will display the National Provider ID of the facility added to the Facility table located in Patients > Ledger > Incident Menu > Incident > Facility of the selected patient's most recent Incident. This data will pull from the 'National Provider ID (NPI)' field located in the selected facility's Reference.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Facility Name: This will display the Name of the Facility added to the Facility table located in Patients > Ledger > Incident Menu > Incident > Facility of the selected patient's most recent Incident. This data will pull from the 'Facility Name' field located in the selected facility's Reference.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Facility Phone: This will display the Phone Number of the facility added to the Facility table located in Patients > Ledger > Incident Menu > Incident > Facility of the selected patient's most recent Incident. This data will pull from the 'Phone' field located in the selected facility's Reference.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Facility State: This will display the State of the facility added to the Facility table located in Patients > Ledger > Incident Menu > Incident > Facility of the selected patient's most recent Incident. This data will pull from the 'State' field located in the selected facility's Reference.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Facility Suite: This will display the Suite Number of the facility added to the Facility table located in Patients > Ledger > Incident Menu > Incident > Facility of the selected patient's most recent Incident. This data will pull from the 'Suite' field located in the selected facility's Reference.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Facility Zip Code: This will display the Zip Code of the facility added to the Facility table located in Patients > Ledger > Incident Menu > Incident > Facility of the selected patient's most recent Incident. This data will pull from the 'Zip Code' field located in the selected facility's Reference.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• First Consultation Date: This will reflect the date as entered in the 'First Consultation' field located in Patients > Ledger > Incident Menu > CMS Claims > Symptom Dates of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• First Symptom: This will display a numeric code reflective of the data selected from the 'First Symptom Date Type' popup located in Patients > Ledger > Incident Menu > CMS Claims > Symptom Dates of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

  • Routine Service: 1

  • Illness: 2

  • Last Menstrual Period: 3

• First Symptom Date: This will reflect the date as entered in the 'First Symptom Date' field located in Patients > Ledger > Incident Menu > CMS Claims > Symptom Dates of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• First Symptom Text: This will display the selected First Symptom for the selected patient's most recent Incident depending on the following scenarios:

IF "AUTO ACCIDENT" HAS BEEN SELECTED FROM THE 'CONDITION RELATED TO' POPUP LOCATED IN PATIENTS > LEDGER > INCIDENT MENU > INCIDENT > REASON FOR TREATMENT:

• This will then display "Accident"

IF "AUTO ACCIDENT" HAS NOT BEEN SELECTED FROM THE 'CONDITION RELATED TO' POPUP:

• This will then display either "Illness" OR "LMP" respective of having selected "Illness" or "Last Menstrual Period" from the 'First Symptom Date Type" popup located in Patients > Ledger > Incident Menu > CMS Claims > Symptom Dates.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Has Date Prior Placement: This is a "True/False" pull field that will display an 'X' respective to having entered a valid date in the 'Box 44 Date Prior Placement' field located in Patients > Ledger > Incident Menu > ADA Claims of the selected patient's most recent Incident.
  [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when a valid date has been entered. If formatted for "False" an 'X' will display when a valid date has not been entered. 2) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Has Enclosures: This is a "True/False" pull field that will display an 'X' respective to having entered data in at least one of the three fields (Radiograph(s)/Oral Image(s)/Model(s)) located in Patients > Ledger > Incident Menu > ADA Claims of the selected patient's most recent Incident.
  [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when data has been entered in the above field(s). If formatted for "False" an 'X' will display when data has not been entered in the above field(s). 2) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Has Similar Symptom Date: This is a "True/False" pull field that will display an 'X' respective to having entered a valid date in the 'Other Date' field located in Patients > Ledger > Incident Menu > CMS Claims > Symptom Dates of the selected patient's most recent Incident.[Note: 1) "Auto Accident" CANNOT be selected from the 'Condition Related To' popup located in Patients > Ledger > Incident Menu > Incident > Reason For Treatment. 2) Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when the above conditions are true. If formatted for "False" an 'X' will display when the above conditions are NOT true. 3) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Incident Date: This will reflect the Name of the Incident as selected/entered in the 'Incident Name' drop down field located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Incident Name: This will reflect the Incident Name as selected/entered in the 'Incident Name' drop down field located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Incident Type: This will reflect the Incident Type as selected/entered in the 'Incident Type' drop down located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Initial Placement: This is a "True/False" pull field that will display an 'X' respective to having selected the 'Initial Placement' checkbox located in Patients > Ledger > Incident menu > Incident > Reason For Treatment of the selected patient's most recent Incident.
  [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the checkbox is selected. If formatted for "False", an 'X' will display when the checkbox is deselected. 2) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident. 3) DDS only.]

• Is Orthodontics: This is a "True/False" pull field that will display an 'X' respective to having selected the 'Orthodontics' checkbox located in Patients > Ledger > Incident menu > Incident > Reason For Treatment of the selected patient's most recent Incident.
  [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the checkbox is selected. If formatted for "False", an 'X' will display when the checkbox is deselected. 2) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident. 3) DDS only.]

• Military Branch: This will display a numeric code reflective of the data as selected from the  'Branch' popup located in the Patients > Ledger > Incident Menu > Military of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]
  [Note: Not available in DDS.]

  • None: 0

  • Army: 1

  • Air Force: 2

  • Marines: 3

  • Navy: 4

  • Coast Guard: 5

  • Public Health Service: 6

  • CHAMP/VA: 7

• Military Branch Air Force: This is a "True/False" pull field that will display an 'X' respective to having selected "Air Force" from the 'Branch' popup located in Patients > Ledger > Incident Menu > Military of the selected patient's most recent Incident.
  [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected. 2) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident. 3) Not available in DDS.]

• Military Branch Army: This is a "True/False" pull field that will display an 'X' respective to having selected "Army" from the 'Branch' popup located in Patients > Ledger > Incident Menu > Military of the selected patient's most recent Incident.
  [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected. 2) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident. 3) Not available in DDS.]

• Military Branch CHAMP/VA: This is a "True/False" pull field that will display an 'X' respective to having selected "CHAMP/VA" from the 'Branch' popup located in Patients > Ledger > Incident Menu > Military of the selected patient's most recent Incident.
  [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected. 2) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident. 3) Not available in DDS.]

• Military Branch Coast Guard: This is a "True/False" pull field that will display an 'X' respective to having selected "Coast Guard" from the 'Branch' popup located in Patients > Ledger > Incident Menu > Military of the selected patient's most recent Incident.
  [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected. 2) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident. 3) Not available in DDS.]

• Military Branch Marines: This is a "True/False" pull field that will display an 'X' respective to having selected "Marines" from the 'Branch' popup located in Patients > Ledger > Incident Menu > Military of the selected patient's most recent Incident.
  [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected. 2) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident. 3) Not available in DDS.]

• Military Branch Navy: This is a "True/False" pull field that will display an 'X' respective to having selected "Navy" from the 'Branch' popup located in Patients > Ledger > Incident Menu > Military of the selected patient's most recent Incident.
  [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected. 2) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident. 3) Not available in DDS.]

• Military Branch Public Health: This is a "True/False" pull field that will display an 'X' respective to having selected "Public Health Service" from the 'Branch' popup located in Patients > Ledger > Incident Menu > Military of the selected patient's most recent Incident.
  [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected. 2) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident. 3) Not available in DDS.]

• Military Date: This will reflect the date as entered in the 'Date' field located in Patients > Ledger > Incident Menu > Military of the selected patient's most recent Incident.
  [Note: 1) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident. 2) Not available in DDS.]

• Military Eligibility: This will display a numeric code reflective of the data as selected from the 'Eligibility' popup located in Patients > Ledger > Incident Menu > Military of the selected patient's most recent Incident.[Note: 1) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident. 2) Not available in DDS.]

  • None: 0

  • Insurance Phone Call: 1

  • Employer Phone Call: 2

  • Payor Card Presented: 3

  • Signed Statement: 4

• Military Status: This will display a numeric code reflective of the data as selected from the 'Status' popup located in Patients > Ledger > Incident Menu > Military of the selected patient's most recent Incident.[Note: 1) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident. 2) Not available in DDS.]

  • None: 0

  • Social Security Number: 1

  • Federal ID: 2

  • Both: 3

• Models: This will reflect the data as entered in the 'Model(s)' field located in Patients > Ledger > Incident Menu > ADA Claims of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Not Accident Related: This is a "True/False" pull field that will display an 'X' respective to having not selected "Auto Accident" or "Other Accident" from the 'Condition Related To' popup located in Patients > Ledger > Incident Menu > Incident > Reason For Treatment of the selected patient's most recent Incident.
  [Note: 1) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident. 2) Functionality dependent upon pull field formatting. This field should be formatted to "True" in which case it will display an 'X' when the above items are NOTselected.]

• Occupational Illness: This is a "True/False" pull field that will display an 'X' respective to having selected the 'Occupational Illness/Injury' checkbox located in Patients > Ledger > Incident Menu > Incident > Reason For Treatment of the selected patient's most recent Incident of the selected patient's most recent Incident.
  [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the checkbox is selected. If formatted for "False", an 'X' will display when the checkbox is not selected. 2) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Oral Images: This will reflect the data as entered in the 'Oral Image(s)' field located in the Incident Menu > ADA Claims of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Other Accident Related: This is a "True/False" pull field that will display an 'X' respective to having selected "Other Accident" from the 'Condition Related To' popup located in in Patients > Ledger > Incident Menu > Incident > Reason For Treatment of the selected patient's most recent Incident.
  [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected. 2) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Other Date Type: This will display a numeric code reflective of the data selected from the 'Other Date Type' popup located in Patients > Ledger > Incident Menu > CMS Claims > Symptom Dates of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

  • Initial Treatment: 454

  • Latest Visit or Consultation: 304

  • Accident: 439

  • Acute Manifestation of a Chronic Condition: 453

  • Last X-ray: 455

  • Prescription: 471

  • Report Start (Assumed Care Date): 090

  • Report End (Relinquished Care Date): 091

  • First Visit or Consultation: 444

• Partial Disability Begin Date: This will reflect the date as entered in the 'Begin Date' field of the 'Partial Disability' section located in Patients > Ledger > Incident Menu > CMS Claims > Disability of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Partial Disability End Date: This will reflect the date as entered in the 'End Date' field of the 'Partial Disability' section located in Patients > Ledger > Incident Menu > CMS Claims > Disability of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Prior Authorization (Blank): [Nonfunctional] (By design?)

• Prior Authorization (None): This will reflect the data as entered in the 'Prior Authorization' field of the first Prior Authorization record listed in the Prior Authorization table located in Patients > Ledger > Incident Menu > Prior Auth of the selected patient's most recent Incident.[Note: 1) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident. 2) This field exhibits odd behavior. This filed can only be used once per incident. Once it has been populated by a prior auth. this data can be changed and deleted, but whatever data (or lack thereof) is present will remain even if the prior auth is deleted.  Subsequently any data from a new prior auth cannot be added, and it will continue to display the deleted prior auth's data. Only by archiving said incident are you able to populate new data.]

• Prosthesis: This is a "True/False" pull filed that will display an 'X' respective to having selected the 'Prosthesis' checkbox located in Patients > Ledger > Incident Menu > Incident > Reason For Treatment of the selected patient's most recent Incident.
  [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the checkbox is selected. If formatted for "False", an 'X' will display when the checkbox is not selected. 2) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Prosthesis Replacement: This is a "True/False" pull field that will display an 'X' respective of having selected the 'Initial Placement' checkbox in coordination with the 'Prothesis' checkbox located in Patients > Ledger > Incident Menu > Incident > Reason For Treatment of the selected patient's most recent Incident.
  [Note: 1) The 'Prosthesis' checkbox MUST be selected. 2) Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when when the checkbox is deselected. If formatted for "False" an 'X' will display when the checkbox is selected. 3) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident. 4) DDS only.]

• Radiographs: This will reflect the data as entered in the 'Radiograph(s)' field located in the Incident Menu > ADA Claims of the selected patient's most recent Incident.
  [Note: 1) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident. 2) DDS only.]

• Referral BC/BS: This will display the BCBS Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'BCBS' field located in the selected referrer's Reference > Provider IDs.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Blue Cross: This will display the Blue Cross Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Blue Cross' field located in the selected referrer's Reference > Provider IDs.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral CHAMPUS: This will display the Champus Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Champus' field located in the selected referrer's Reference > Provider IDs.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Central Certification: This will display the Central Certification Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Central Certification' field located in the selected referrer's Reference > Provider IDs.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral City: This will display the City of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'City' field located in the selected referrer's Reference > Referrer Info.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Commercial: This will display the Commercial Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Commercial' field located in the selected referrer's Reference > Provider IDs.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Date: This will display the Referral Date of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Referral Date' field of the selected referrer's record found in the Referrals table located in Patients > Patient > Referrals.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Email: This will display the Email Address of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Email' field located in the selected referrer's Reference > Referrer Info.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Federal Employee: This will display the Federal Employee Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Federal Employee' field located in the selected referrer's Reference > Provider IDs.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral First Name: This will display the First Name of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident of the selected patient's most recent Incident. This data will pull from the 'First Name' field located in the selected referrer's Reference > Referrer Info.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral HMO: This will display the Health Maintenance Organization Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident of the selected patient's most recent Incident. This data will pull from the 'HMO' field located in the selected referrer's Reference > Provider IDs.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Is Person: This is a "True/False" pull field that will display an 'X' respective to having selected the 'Is Person' checkbox located in the Reference > Referrer Info for the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident.
  [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the checkbox is selected. If formatted for "False", an 'X' will display when the checkbox is deselected. 2) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Last Name: This will display the Last Name of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Last Name' field located in the selected referrer's Reference > Referrer Info.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Managed Care: This will display the Managed Care Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Managed Care' field located in the selected referrer's Reference > Provider IDs.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Medicaid: This will display the Medicaid Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Medicaid' field located in the selected referrer's Reference > Provider IDs.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Medicare: This will display the Medicare Part B Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Medicare Part B' field located in the selected referrer's Reference > Provider IDs.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Middle Name: This will display the Middle Name of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Middle Name' field located in the selected referrer's Reference > Referrer Info.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Nickname: This will display the Nickname of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Nickname' field located in the selected referrer's Reference > Referrer Info.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Other: This will display the Other Non-Federal Number of the referral selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Other Non-Federal' field located in the selected referrer's Reference > Provider IDs.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Other Federal: This will display the Other Federal Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Other Federal' field located in the selected referrer's Reference > Provider IDs.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral PPO: This will display the PPO number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'PPO' field located in the selected referrer's Reference > Provider IDs.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Phone 1: This will display the Phone 1 Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the first 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Phone 1 Type: This will display a numeric code reflective of the Phone 1 Type (Home/Work/Cell/Fax) for the referrer selected form the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull as selected from the "Type" popup directly to the left of the first phone number field under the 'Phone Numbers' section located in the selected referrer's Reference > Referrer Info.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]
  
  

  • Home: 0

  • Work: 1

  • Cell: 2

  • Fax: 3

• Referral Phone 2: This will display the Phone 2 Number for the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the second 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Phone 2 Type: This will display a numeric code reflective of the Phone 2 Type (Home/Work/Cell/Fax) for the referrer selected form the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will as selected from the "Type" popup directly to the left of the second phone number field under the 'Phone Numbers' section located in the selected referrer's Reference > Referrer Info.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]
  
  

  • Home: 0

  • Work: 1

  • Cell: 2

  • Fax: 3

• Referral Phone 3: This will display the Phone 3 Number for the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the third 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Phone 3 Type: This will display a numeric code reflective of the Phone 3 Type (Home/Work/Cell/Fax) for the referral selected form the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull as selected from the "Type" popup directly to the left of the third phone number field under the 'Phone Numbers' section located in the selected referrer's Reference > Referrer Info.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]
  
  

  • Home: 0

  • Work: 1

  • Cell: 2

  • Fax: 3

• Referral Professional Title: This will display the Professional Title of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Prefix' field located in the selected referrer's Reference > Referrer Info.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Self Administration: This will display the Self Administration Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Self Admin' field located in the selected referrer's Reference > Provider IDs.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Self Pay: This will display the Self Pay Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Self Pay' field located in the selected referrer's Reference > Provider IDs.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral State: This will display the State of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'State' field located in the selected referrer's Reference > Referrer Info.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Street Address: This will display the Street Address of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Street Address' field located in the selected referrer's Reference > Referrer Info.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Suffix: This will display the Suffix of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Suffix' field located in the selected referrer's Reference > Referrer Info.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Suite: This will display the Suite Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Suite' field located in the selected referrer's Reference > Referrer Info.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Taxonomy Code: This will display the Taxonomy Code of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Taxonomy (Specialty Code)' field located in the selected referrer's Reference > Referrer Info.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Title V: This will display the Title V Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Title V' field located in the selected referrer's Reference > Provider IDs.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Type: This will display the Referral Type associated with the referrer selected from the 'Referral' dropdown located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Referrer Type' drop down located in the selected referrer's Reference > Referrer Info.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Type Emergency: This is a "True/False" pull field that will display an 'X' respective to having selected a referrer from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident (of the selected patient's most recent Incident) with a referral type containing the word "emergency". This data pulls from the 'Referral Type' dropdown located in the selected referrer's Reference > Referrer Info.
  [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the selected Referral Type contains the word "emergency". If formatted for "False", an 'X' will display when the selected Referral Type does not contain the word "emergency". 2) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Type Patient: This is a "True/False" pull field that will display an 'X' respective to having selected a referrer from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident (of the selected patient's most recent Incident) with a referral type containing the word "Patient". This data pulls from the 'Referral Type' dropdown located in the selected referrer's Reference > Referrer Info.
  [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the selected Referral Type contains the word "patient". If formatted for "False", an 'X' will display when the selected Referral Type does not contain the word "patient". 2) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Type Phone Book: This is a "True/False" pull field that will display an 'X' respective to having selected a referrer from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident (of the selected patient's most recent Incident) with a referral type containing the word "Phone Book". This data pulls from the 'Referral Type' dropdown located in the selected referrer's Reference > Referrer Info.
  [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the selected Referral Type contains the words "phone book". If formatted for "False", an 'X' will display when the selected Referral Type does not contain the words "phone book". 2) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Type Provider: This is a "True/False" pull field that will display an 'X' respective to having selected a referrer from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident (of the selected patient's most recent Incident) with a referral type containing the word "Provider". This data pulls from the 'Referral Type' dropdown located in the selected referrer's Reference > Referrer Info.
  [Note: 1) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the selected Referral Type contains the word "provider". If formatted for "False", an 'X' will display when the selected Referral Type does not contain the word "provider". 2) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Veterans Administration: This will display the Veterans Administration Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Vets Admin.' field located in the selected referrer's Reference > Provider IDs.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Workers Compensation: This will display the Workers Compensation Number of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Workers Compensation' field located in the selected referrer's Reference > Provider IDs.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Referral Zip Code: This will display the Zip Code of the referrer selected from the 'Referral' popup located in Patients > Ledger > Incident Menu > Incident of the selected patient's most recent Incident. This data will pull from the 'Zip Code' field located in the selected referrer's Reference > Referrer Info.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Return To Work Date: This will reflect the date as entered in the 'Return To Work' field located in Patients > Ledger > Incident Menu > CMS Claims > Disability of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

•  Similar Symptom Date: This will reflect the date as entered in the 'Other Date' field located in Patients > Ledger > Incident Menu > CMS Claims > Symptom Dates of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Termination Date: This will reflect the date as entered in the 'Termination Date' field located in Patients > Ledger > Incident Menu > Military of the selected patient's most recent Incident.
  [Note: 1) The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident. 2) Not available in DDS.]

• Total Disability Begin Date: This will reflect the date as entered in the 'Begin Date' field under the 'Total Disability' section located in Patients > Ledger > Incident Menu > CMS Claims > Disability of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Total Disability End Date: This will reflect the date as entered in the 'End Date' field under the 'Total Disability' section located in Patients > Ledger > Incident Menu > CMS Claims > Disability of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Unable To Work Begin Date: This will reflect the date as entered in the 'Begin Date' field under the 'Total Disability' section located in Patients > Ledger > Incident Menu > CMS Claims > Disability of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

• Unable To Work End Date: This will reflect the date as entered in the 'End Date' field under the 'Total Disability' section located in Patients > Ledger > Incident Menu > CMS Claims > Disability of the selected patient's most recent Incident.
  [Note: The most recent Incident is determined by the 'Incident Date' field located in the Incident tab of the selected Incident.]

Miscellaneous

• Created By ID: This will display the User ID of the logged in user responsible for having printed the Patient Form. This data will pull from the 'User ID' field located in the respective user's Reference > User Information.

• Created By Name: This will display the First and Last Name of the logged in user responsible for having printed the Patient Form. This data will pull from the 'First' and 'Last' fields located in the respective user's Reference > User Information.

• Created By Name, First: This will display the First Name of the logged in user responsible for having printed the Patient Form. This data will pull from the 'First' field located in the respective user's Reference > User Information.

• Created By Name, Last: This will display the Last Name of the logged in user responsible for having printed the Patient Form. This data will pull from the 'Last' field located in the respective user's Reference > User Information.

• Created By Name, Middle: This will display the Middle Name of the logged in user responsible for having printed the Patient Form. This data will pull from the 'Middle' field located in the respective user's Reference > User Information.

• Created By Name, Suffix: This will display the Suffix of the logged in user responsible for having printed the Patient Form. This data will pull from the 'Suffix' field located in the respective user's Reference > User Information.

• Created By Name, Title: This will display the Professional Title of the logged in user responsible for having printed the Patient Form. This data will pull from the 'Professional Title' field located in the respective user's Reference > User Information.

• Time Now: This will display the current time at the moment the Patient Form is printed.

• Today's Date: This will display the date of the day the Patient Form is printed on.

Office

• City: This will display the City of the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'City' field located in the selected office's Reference.
  [Note: This field is inaccessible and can only be changed or updated by the Accounting Department.]

• Extension: This will display the Phone Extension of the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'Extension' field located in the selected office's Reference.

• Facility City: This will display the City of the Office's facility for the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'City' field found in the Reference of the facility selected from the Facility table located in the selected office's Reference.

• Facility Code: This will display the Tax ID of the Office's facility for the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'Facility Tax ID' field found in the Reference of the facility selected from the Facility table located in the selected office's Reference.

• Facility Code 2: This will display the Secondary Facility ID of the Office's facility for the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'Secondary Facility ID' field found in the Reference of the facility selected from the Facility table located in the selected office's Reference.

• Facility Name: This will display the Name of the Office's facility for the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'Facility Name' field found in the Reference of the facility selected from the Facility table located in the selected office's Reference.

• Facility National Provider ID: This will display the NPI of the Office's facility for the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'National Provider ID (NPI)' field found in the Reference of the facility selected from the Facility table located in the selected office's Reference.

• Facility Phone: This will display the Phone Number of the Office's facility for the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'Phone' field found in the Reference of the facility selected from the Facility table located in the selected office's Reference.

• Facility State: This will display the State of the Office's facility for the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'State' field found in the Reference of the facility selected from the Facility table located in the selected office's Reference.

• Facility Street Address: This will display the Street Address of the Office's facility for the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'Street Address' field found in the Reference of the facility selected from the Facility table located in the selected office's Reference.

• Facility Suite: This will display the Suite Number of the Office's facility for the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'Suite' field found in the Reference of the facility selected from the Facility table located in the selected office's Reference.

• Facility Zip Code: This will display the Zip Code of the Office's facility for the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'National Provider ID (NPI)' field found in the Reference of the facility selected from the Facility table located in the selected office's Reference.

• Fax: This will display the Fax Number of the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'Fax' field located in the selected office's Reference.

• Group NPI Number: This will display the Group NPI of the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'Group National Provider ID Number' field located in the selected office's Reference.

• ID: This will display the Office ID of the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'Office ID' field located in the selected office's Reference.

• Is Person: This is a "True/False" pull field that will display an 'X' respective to having selected the 'Office Name refers to an individual' checkbox located in the Reference for the Office selected from the 'Office' popup located in Patients > Patient.
  [Note: Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the checkbox is selected. If formatted for "False", an 'X' will display when the checkbox is deselected.]

• Name: This will display the Name of the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'Office Name' field located in the selected office's Reference.
  [Note: This field is inaccessible and can only be changed or updated by the Accounting Department.]

• Office Federal Number: This will display the Tax ID of the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'Federal Tax ID' field located in the selected office's Reference.

• Office Letter Head: This will display the City, State, and Zip Code of the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'City', 'State', and 'Zip Code' fields located in the selected office's Reference.
  [Note: These fields are inaccessible and can only be changed or updated by the Accounting Department.]

• Phone: This will display the Phone Number of the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'Phone' field of the selected office's Reference.

• State: This will display the State of the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'State' field of the selected office's Reference.
  [Note: This field is inaccessible and can only be changed or updated by the Accounting Department.]

• Street Address: This will display the Street Address of the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'Street Address' field located in the selected office's Reference.
  [Note: This field is inaccessible and can only be changed or updated by the Accounting Department.]

• Suite: This will display the Suite Number of the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'Suite' field of the selected office's Reference.
  [Note: This field is inaccessible and can only be changed or updated by the Accounting Department.]

• Type Of Bill: This will display the Type Of Bill data of the office selected form the 'Office' popup located in Patients > Patient. This data will pull from the 'Type Of Bill' field located in the selected office's Reference.

• Zip Code: This will display the Zip Code of the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'Zip Code' field located in the selected office's Reference.
  [Note: This field is inaccessible and can only be changed or updated by the Accounting Department.]

Patient

• Account ID: Upon creation, every new patient account will receive a unique numeric identifier including an additional numeric identifier for every patient tied to that account. This pull field will display the numeric account identifier that was assigned to the account at the moment of creation less the patient identifier.

• Address State: This will reflect the data as entered in the 'State' field located in Patients > Patient.

• Address, City: This will reflect the data as entered in the 'City' field located in Patients > Patient.

• Address, Country: This will reflect the data as entered in the 'Country' field located in Patients > Patient.

• Address, Street: This will reflect the data as entered in the 'Street Address' field located in Patients > Patient.

• Address, Suite/Apt#: This will reflect the data as entered in the 'Suite/Apt. Number' field located in Patients > Patient.

• Address, Zip Code: This will reflect the data as entered in the 'Zip Code' field located in Patients > Patient.

• Age: This will display the Age of the patient as determined by the date of birth as entered in the 'Birth Date' field located in Patients > Patient.

• Alert 1: This will display the first Alert record listed in Patients > Patient > Alerts. This data will pull from the 'Patient Alert Description' field located in the selected alert's Reference.

• Alert 2: This will display the second Alert record listed in Patients > Patient > Alerts. This data will pull from the 'Patient Alert Description' field located in the selected alert's Reference.

• Alert 3: This will display the third Alert record listed in Patients > Patient > Alerts. This data will pull from the 'Patient Alert Description' field located in the selected alert's Reference.

• Alert 4: This will display the fourth Alert record listed in Patients > Patient > Alerts. This data will pull from the 'Patient Alert Description' field located in the selected alert's Reference.

• Alert 5: This will display the fifth Alert record listed in Patients > Patient > Alerts. This data will pull from the 'Patient Alert Description' field located in the selected alert's Reference.

• Alert 6: This will display the sixth Alert record listed in Patients > Patient > Alerts. This data will pull from the 'Patient Alert Description' field located in the selected alert's Reference.

• Alert 7: This will display the seventh Alert record listed in Patients > Patient > Alerts. This data will pull from the 'Patient Alert Description' field located in the selected alert's Reference.

• Alert 8: This will display the eighth Alert record listed in Patients > Patient > Alerts. This data will pull from the 'Patient Alert Description' field located in the selected alert's Reference.

• Allergy Date Last Checked: This will reflect the date as entered in the 'Last' field located in Patients > Clinical > Allergy.

• BMI: This will display the patient's Body Mass Index (rounded to the nearest decimal) for the most recent set of vital signs added to Patients > Clinical > Vitals. This data will pull from the 'BMI' field located in the selected record's Vitals Window.
  [Note: The most recent set of vitals is determined by the last record listed in the Vitals tab (most recent date entered in the 'Date Measured' field located in the Vital's Window).]

• BP Diastolic: This will display the Diastolic Blood Pressure for the most recent set of vital signs added to Patients > Clinical > Vitals. This data will pull from the rightmost 'Blood Pressure' field (Systolic / Diastolic) located in the selected record's Vitals Window.
  [Note: The most recent set of vitals is determined by the last record listed in the Vitals tab (most recent date entered in the 'Date Measured' field located in the Vital's Window).]

• BP Systolic: This will display the Systolic Blood Pressure for the most recent set of vital signs added to the Vitals table located in Patients > Clinical > Vitals. This data will pull from the leftmost 'Blood Pressure' field (Systolic / Diastolic) located in the selected record's Vitals Window.
  [Note: The most recent set of vitals is determined by the last record listed in the Vitals tab (most recent date entered in the 'Date Measured' field located in the Vital's Window).]

• Birth Time: This will display the time as entered in the 'Birth Time' field located in the Details window of the 'Birth Date' field located in Patients > Patient.

• Birthday: This will reflect the date as entered in the 'Birth Date' field located in Patients > Patient.

• Cause of Death Code: This will display the diagnosis code reflective of the Cause of Death selected from the 'Cause of Death' field located in Patients > Patient > Alerts.

• Cause of Death Description: This will display the specific description reflective of the Cause of Death selected from the 'Cause of Death' field located in Patients > Patient > Alerts.

• Cessation Counseling Date: This will display the date that cessation counseling was offered to the patient for the most recently updated Cessation record listed in Patients > Clinical > Smoking (first listed record). This data will pull from the 'Date Offered' field located in the selected records's Smoking Status Window.

• Cessation Counseling Offered: This is a "True/False" pull field that will display an 'X' respective to having selected the 'Cessation Counseling Offered' checkbox located in the Smoking Status Window of the most recently updated Smoking Status record located in Patients > Clinical > Smoking (first listed record).
  [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when the checkbox is selected. If formatted for "False" an 'X' will display when the checkbox is not selected.]

• Chart #: This will reflect the data as entered in the 'Chart #' field located in Patients > Patient.

• Custom 1: This will display the first Custom record listed in Patients > Patient > Custom. This data will pull from the 'Custom Description' field located in the selected record's Reference.

• Custom 2: This will display the second Custom record listed in Patients > Patient > Custom. This data will pull from the 'Custom Description' located in the selected record's Reference.

• Custom 3: This will display the third Custom record listed in Patients > Patient > Custom. This data will pull from the 'Custom Description' located in the selected record's Reference.

• Custom 4: This will display the fourth Custom record listed in Patients > Patient > Custom. This data will pull from the 'Custom Description' located in the selected record's Reference.

• Custom 5: This will display the fifth Custom record listed in Patients > Patient > Custom. This data will pull from the 'Custom Description' located in the selected record's Reference.

• Custom 6: This will display the sixth Custom record listed in Patients > Patient > Custom. This data will pull from the 'Custom Description' located in the selected record's Reference.

• Custom 7: This will display the seventh Custom record listed in Patients > Patient > Custom. This data will pull from the 'Custom Description' located in the selected record's Reference

• Custom 8: This will display the eighth Custom record in Patients > Patient > Custom. This data will pull from the 'Custom Description' located in the selected record's Reference.

• Date: This will display the date the patient's vital signs were measured for the most recent set of vital signs added to Patients > Clinical > Vitals. This data will pull from the 'Date Measured' field located the selected entry's Vitals Window.
  [Note: The most recent set of vitals is determined by the last record listed in the Vitals tab (most recent date entered in the 'Date Measured' field located in the Vital's Window).]

• Date of Death: This will reflect the date as entered in the 'Date of Death' field located in Patients > Patient > Alerts.

• Display ID: Upon creation, every new patient account will receive a unique numeric identifier including a numeric identifier for every patient tied to that account. This pull field will display the full numeric account identifier and numeric patient identifier that were assigned at the moment of creation.

• EPSTD (Early Periodic Screening Diagnosis and Treatment): This is a "True/False" pull field that will display an 'X' respective to having selected the 'EPSDT' checkbox located in Patients > Patient > Insurance.
  [Note: Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the checkbox is selected. If formatted for "False", an 'X' will display when the checkbox is deselected.]

• Email: This will reflect the data as entered in the 'Email Address' field located in Patients > Patient.

• Emergency Contact 1 First Name: This will display the First Name of the first Emergency Contact record listed in Patients > Patient > Emergency. This data will pull from the 'First Name' field located in the selected record's Emergency Contact Window.
  [Note: The order of the listed emergency contacts is determined by dragging and dropping the entries into the desired order.]

• Emergency Contact 1 Last Name: This will display the Last Name of the first Emergency Contact record listed in Patients > Patient > Emergency. This data will pull from the 'Last Name' field located in the selected record's Emergency Contact Window.
  [Note: The order of the listed emergency contacts is determined by dragging and dropping the entries into the desired order.]

• Emergency Contact 1 Phone: This will display the Phone Number of the first Emergency Contact record listed in Patients > Patient > Emergency. This data will pull from the 'Phone' field located in the selected record's Emergency Contact Window.
  [Note: The order of the listed emergency contacts is determined by dragging and dropping the entries into the desired order.]

• Emergency Contact 1 Relationship: This will display the Relationship of the first Emergency Contact record listed in Patients > Patient > Emergency. This pull field will reflect the data selected from the 'Relationship to Patient' field located in the selected record's Emergency Contact Window.
  [Note: The order of the listed emergency contacts is determined by dragging and dropping the entries into the desired order.]

• Emergency Contact 2 First Name: This will display the First Name of the second Emergency Contact record listed in Patients > Patient > Emergency. This data will pull from the 'First Name' field located in the selected record's Emergency Contact Window.
  [Note: The order of the listed emergency contacts is determined by dragging and dropping the entries into the desired order.]

• Emergency Contact 2 Last Name: This will display the Last Name of the second Emergency Contact record listed in Patients > Patient > Emergency. This data will pull from the 'Last Name' field of the selected record's Emergency Contact Window.
  [Note: The order of the listed emergency contacts is determined by dragging and dropping the entries into the desired order.]

• Emergency Contact 2 Phone: This will display the Phone Number of the second Emergency Contact record listed in Patients > Patient > Emergency. This data will pull from the 'Phone' field located in the selected record's Emergency Contact Window.
  [Note: The order of the listed emergency contacts is determined by dragging and dropping the entries into the desired order.]

• Emergency Contact 2 Relationship: This will display the Relationship of the second Emergency Contact record listed in Patients > Patient > Emergency. This pull field will reflect the data selected from the 'Relationship to Patient' field located in the selected record's Emergency Contact Window.
  [Note: The order of the listed emergency contacts is determined by dragging and dropping the entries into the desired order.]

• Emergency Contact 3 First Name: This will display the First Name of the third Emergency Contact record listed in Patients > Patient > Emergency. This data will pull from the 'First Name' field of the selected record's Emergency Contact Window.
  [Note: The order of the listed emergency contacts is determined by dragging and dropping the entries into the desired order.]

• Emergency Contact 3 Last Name: This will display the Last Name of the third Emergency Contact record listed in Patients > Patient > Emergency. This data will pull from the 'Last Name' field of the selected record's Emergency Contact Window.
  [Note: The order of the listed emergency contacts is determined by dragging and dropping the entries into the desired order.]

• Emergency Contact 3 Phone: This will display the Phone Number of the third Emergency Contact record listed in Patients > Patient > Emergency. This data will pull from the 'Phone' field located in the selected record's Emergency Contact Window.
  [Note: The order of the listed emergency contacts is determined by dragging and dropping the entries into the desired order.]

• Emergency Contact 3 Relationship: This will display the Relationship of the third Emergency Contact record listed in Patients > Patient > Emergency. This pull field will reflect the data selected from the 'Relationship to Patient' field located in the selected record's Emergency Contact Window.
  [Note: The order of the listed emergency contacts is determined by dragging and dropping the entries into the desired order.]

• Emergency Contact 4 First Name: This will display the First Name of the fourth Emergency Contact record listed in Patients > Patient > Emergency. This data will pull from the 'First Name' field of the selected record's Emergency Contact Window.
  [Note: The order of the listed emergency contacts is determined by dragging and dropping the entries into the desired order.]

• Emergency Contact 4 Last Name: This will display the Last Name of the fourth Emergency Contact record listed in Patients > Patient > Emergency. This data will pull from the 'Last Name' field of the selected record's Emergency Contact Window.
  [Note: The order of the listed emergency contacts is determined by dragging and dropping the entries into the desired order.]

• Emergency Contact 4 Phone: This will display the Phone Number of the fourth Emergency Contact record listed in Patients > Patient > Emergency. This data will pull from the 'Phone' field located in the selected record's Emergency Contact Window.
  [Note: The order of the listed emergency contacts is determined by dragging and dropping the entries into the desired order.]

• Emergency Contact 4 Relationship: This will display the Relationship of the fourth Emergency Contact record listed in Patients > Patient > Emergency. This pull field will reflect the data selected from the 'Relationship to Patient' field located in the selected record's Emergency Contact Window.
  [Note: The order of the listed emergency contacts is determined by dragging and dropping the entries into the desired order.]

• Employment: This will display the numeric code reflective of the selected employment status found in the 'Employment' popup located in Patients > Patient.

• Employment (Text): This will reflect the Employment Status as selected from the 'Employment' popup located in Patients > Patient.

• Ethnicity: This will reflect the Ethnicity as selected from the 'Ethnicity' popup located Patients > Patient > Race/Ethnicity.

• Exception: This will reflect the Exception as selected from the 'Patient Exception' popup located in Patients > Patient > CDA.
  [Note: The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization.]

• Exception - Is Disabled: This will display an 'X' respective to having selected "Disabled" from the 'Patient Exception' popup located in Patients > Patient > CDA.
  [Note: 1) The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization. 2) Pull field formatting MUST be set to "Text".]

• Exception - Is Disabled Student: This will display an 'X' respective to having selected "Disabled Student" from the 'Patient Exception' popup located in Patients > Patient > CDA.
  [Note: 1) The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization. 2) Pull field formatting MUST be set to "Text".]

• Family Planning: This is a "True/False" pull field that will display an 'X' respective to having selected the 'Family Planning' checkbox located in Patients > Patient > Insurance.
  [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when the checkbox is selected. If formatted for "False" an 'X' will display when the checkbox is not selected.]

• Fee Schedule Name: This will display the Fee Schedule Name as selected from the 'Fee Schedule' popup located in Patients > Patient.

• Follow Up/Recall 1 Frequency: This will reflect the Recall Frequency number as displayed/entered in the 'Frequency' field of the first Recall record listed in Patients > Patient > Recalls/Follow-ups. This data will pull from the 'Frequency In Days' field located in the selected recall's Reference but can be edited from the Recalls/Follow-ups tab.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 1 Last Visit: This will reflect the date as displayed/entered in the 'Last Visit' field of the first Recall record listed in Patients > Patient > Recalls/Follow-ups. This field will default to the date the selected recall was created on but can be edited.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 1 Next Visit: This will reflect the date as displayed/entered in the 'Next Visit' field of the first Recall record listed in Patients > Patient > Recalls/Follow-ups. This field will default to the date as determined by the last visit date plus the frequency number of the selected recall but can be edited.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 1 Notes: This will reflect the data as entered in the 'Notes' field of the first Recall record listed in Patients > Patient > Recalls/Follow-ups.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 1 Type: This will display the Recall Type as found under the 'Type' column of the first Recall record listed in Patients > Patient > Recalls. This data will pull from the 'Recall' field of the selected recall's Reference.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 2 Frequency: This will reflect the Recall Frequency number as displayed/entered in the 'Frequency' field of the second Recall record listed in Patients > Patient > Recalls/Follow-ups. This data will pull from the 'Frequency In Days' field located in the selected recall's Reference but can be edited from the Recalls/Follow-ups tab.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 2 Last Visit: This will reflect the date as displayed/entered in the 'Last Visit' field of the second Recall record listed in Patients > Patient > Recalls/Follow-ups. This field will default to the date the selected recall was created on but can be edited.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 2 Next Visit: This will reflect the date as displayed/entered in the 'Next Visit' field of the second Recall record listed in Patients > Patient > Recalls/Follow-ups. This field will default to the date as determined by the last visit date plus the frequency number of the selected recall but can be edited.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 2 Notes: This will reflect the data as entered in the 'Notes' field of the second Recall record listed in Patients > Patient > Recalls/Follow-ups.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 2 Type: This will display the Recall Type as found under the 'Type' column of the second Recall record listed in Patients > Patient > Recalls/Follow-ups. This data will pull from the 'Recall' field of the selected recall's Reference.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 3 Frequency: This will reflect the Recall Frequency number as displayed/entered in the 'Frequency' field of the third Recall record listed in Patients > Patient > Recalls/Follow-ups. This data will pull from the 'Frequency In Days' field located in the selected recall's Reference but can be edited from the Recalls/Follow-ups tab.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 3 Last Visit: This will reflect the date as displayed/entered in the 'Last Visit' field of the third Recall record listed in Patients > Patient > Recalls/Follow-ups. This field will default to the date the selected recall was created on but can be edited.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 3 Next Visit: This will reflect the date as displayed/entered in the 'Next Visit' field of the third Recall record listed in Patients > Patient > Recalls/Follow-ups. This field will default to the date as determined by the last visit date plus the frequency number of the selected recall but can be edited.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 3 Notes: This will reflect the data as entered in the 'Notes' field of the third Recall record listed in Patients > Patient > Recalls/Follow-ups.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 3 Type: This will display the Recall Type as found under the 'Type' column of the third Recall record listed in Patients > Patient > Recalls/Follow-ups. This data will pull from the 'Recall' field of the selected recall's Reference.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 4 Frequency: This will reflect the Recall Frequency number as displayed/entered in the 'Frequency' field of the fourth Recall record listed in Patients > Patient > Recalls/Follow-ups. This data will pull from the 'Frequency In Days' field located in the selected recall's Reference but can be edited from the Recalls/Follow-ups tab.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 4 Last Visit: This will reflect the date as displayed/entered in the 'Last Visit' field of the fourth Recall record listed in Patients > Patient > Recalls/Follow-ups. This field will default to the date the selected recall was created on but can be edited.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 4 Next Visit: This will reflect the date as displayed/entered in the 'Next Visit' field of the fourth Recall record listed in Patients > Patient > Recalls/Follow-ups. This field will default to the date as determined by the last visit date plus the frequency number of the selected recall but can be edited.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 4 Notes: This will reflect the data as entered in the 'Notes' field of the fourth Recall record listed in Patients > Patient > Recalls/Follow-ups.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 4 Type: This will display the Recall Type as found under the 'Type' column of the fourth Recall record listed in Patients > Patient > Recalls/Follow-ups. This data will pull from the 'Recall' field of the selected recall's Reference.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 5 Frequency: This will reflect the Recall Frequency number as displayed/entered in the 'Frequency' field of the fifth Recall record listed in Patients > Patient > Recalls/Follow-ups. This data will pull from the 'Frequency In Days' field located in the selected recall's Reference but can be edited from the Recalls/Follow-ups tab.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 5 Last Visit: This will reflect the date as displayed/entered in the 'Last Visit' field of the fifth Recall record listed in Patients > Patient > Recalls/Follow-ups. This field will default to the date the selected recall was created on but can be edited.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 5 Next Visit: This will reflect the date as displayed/entered in the 'Next Visit' field of the fifth Recall record listed in Patients > Patient > Recalls/Follow-ups. This field will default to the date as determined by the last visit date plus the frequency number of the selected recall but can be edited.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 5 Notes: This will reflect the data as entered in the 'Notes' field of the fifth Recall record listed in Patients > Patient > Recalls/Follow-ups.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 5 Type: This will display the Recall Type as found under the 'Type' column of the fifth Recall record listed in Patients > Patient > Recalls/Follow-ups. This data will pull from the 'Recall' field of the selected recall's Reference.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 6 Frequency: This will reflect the Recall Frequency number as displayed/entered in the 'Frequency' field of the sixth Recall record listed in Patients > Patient > Recalls/Follow-ups. This data will pull from the 'Frequency In Days' field located in the selected recall's Reference but can be edited from the Recalls/Follow-ups tab.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 6 Last Visit: This will reflect the date as displayed/entered in the 'Last Visit' field of the sixth Recall record listed in Patients > Patient > Recalls/Follow-ups. This field will default to the date the selected recall was created on but can be edited.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 6 Next Visit: This will reflect the date as displayed/entered in the 'Next Visit' field of the sixth Recall record listed in Patients > Patient > Recalls/Follow-ups. This field will default to the date as determined by the last visit date plus the frequency number of the selected recall but can be edited.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 6 Notes: This will reflect the data as entered in the 'Notes' field of the sixth Recall record listed in Patients > Patient > Recalls/Follow-ups.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 6 Type: This will display the Recall Type as found under the 'Type' column of the sixth Recall record listed in Patients > Patient > Recalls/Follow-ups. This data will pull from the 'Recall' field of the selected recall's Reference.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 7 Frequency: This will reflect the Recall Frequency number as displayed/entered in the 'Frequency' field of the seventh Recall record listed in Patients > Patient > Recalls/Follow-ups. This data will pull from the 'Frequency In Days' field located in the selected recall's Reference but can be edited from the Recalls/Follow-ups tab.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 7 Last Visit: This will reflect the date as displayed/entered in the 'Last Visit' field of the seventh Recall record listed in Patients > Patient > Recalls/Follow-ups. This field will default to the date the selected recall was created on but can be edited.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 7 Next Visit: This will reflect the date as displayed/entered in the 'Next Visit' field of the seventh Recall record listed in Patients > Patient > Recalls/Follow-ups. This field will default to the date as determined by the last visit date plus the frequency number of the selected recall but can be edited.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 7 Notes: This will reflect the data as entered in the 'Notes' field of the seventh Recall record listed in Patients > Patient > Recalls/Follow-ups.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 7 Type: This will display the Recall Type as found under the 'Type' column of the seventh recall Recall listed in Patients > Patient > Recalls/Follow-ups. This data will pull from the 'Recall' field of the selected recall's Reference. [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 8 Frequency: This will reflect the Recall Frequency number as displayed/entered in the 'Frequency' field of the eighth Recall record in Patients > Patient > Recalls/Follow-ups. This data will pull from the 'Frequency In Days' field located in the selected recall's Reference but can be edited from the Recalls/Follow-ups tab.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 8 Last Visit: This will reflect the date as displayed/entered in the 'Last Visit' field of the eighth Recall record listed in Patients > Patient > Recalls/Follow-ups. This field will default to the date the selected recall was created on but can be edited.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 8 Next Visit: This will reflect the date as displayed/entered in the 'Next Visit' field of the eighth Recall record listed Patients > Patient > Recalls/Follow-ups. This field will default to the date as determined by the last visit date plus the frequency number of the selected recall but can be edited.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 8 Notes: This will reflect the data as entered in the 'Notes' field of the eighth Recall record listed in Patients > Patient > Recalls/Follow-ups.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall 8 Type: This will display the Recall Type as found under the 'Type' column of the eighth Recall record listed Patients > Patient > Recalls/Follow-ups. This data will pull from the 'Recall' field of the selected recall's Reference.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall Appointment: This will display the date of the scheduled Recall Appointment for the first Recall record listed in Patients > Patient > Recalls/Follow-ups.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall Appointment Note: This will display the Notes of the scheduled recall appointment for the first Recall record in Patients > Patient > Recalls/Follow-ups. This data will pull from the 'Notes' field located in the Appointment Detail Window of the scheduled appointment for the selected recall.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall Appointment Time: This will display the Appointment Start Time of the scheduled recall appointment for the first Recall record listed in Patients > Patient > Recalls/Follow-ups.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall Appointment Frequency: This will reflect the data as displayed/entered in the 'Frequency' field of the first Recall record listed in Patients > Patient > Recalls/Follow-ups (after being tied to a scheduled appointment). This data will pull from the 'Frequency In Days' field located in the selected recall's Reference but can be edited from the Recalls/Follow-ups tab.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall Last Recall: This will reflect the date as displayed/entered in the 'Last Visit' field of the Recall record with the most recent last visit date listed in Patients > Patient > Recalls/Follow-ups. This field will default to the date the selected recall was created on but can be edited.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall Next Recall: This will reflect the date as displayed/entered in the 'Next Visit' field of the Recall record with the closest next visit date listed in Patients > Patient > Recalls/Follow-ups. This field will default to the date as determined by the last visit date plus the frequency number of the selected recall but can be edited.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall Recall: This will display the date as found under the 'Recall Date' column of the first Recall record listed in Patients > Patient > Recalls/Follow-ups.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Follow Up/Recall Type: This will display the Recall Type as found under the 'Type' column of the first Recall record listed in Patients > Patient > Recalls/Follow-ups.
  [Note: The order of the listed recalls is determined by dragging and dropping the entries into the desired order.]

• Formatted Age: This will display the Age of the patient followed by a 'y' as determined by the date of birth as entered in the 'Birth Date' field located in Patients > Patient.

• Gender Pronoun (He/She): This will display "he" or "she" respective to having selected "Male" or "Female" from the 'Sex' popup located in Patients > Patient.

• Gender Pronoun (Him/Her): This will display "him" or "her" respective to having selected "Male" or "Female" from the 'Sex' popup located in Patients > Patient.

• Gender Pronoun (His/Her): This will display "his" or "hers" respective to having selected "Male" or "Female" from the 'Sex' popup located in Patients > Patient.

• HIPAA Release: This will reflect the data as selected from the 'HIPAA Release' popup located in Patients > Patient > Insurance.

• HIPAA Release Date: This will reflect the date as entered in the 'Date' field located in Patients > Patient > Insurance. 

• Heart Rate: This will display the Heart Rate as found under the 'Heart Rate' column of the most recent set of vital signs entered in the Vitals table located in Patients > Clinical > Vitals. This data will pull from the 'Heart Rate' field located in the selected entry's Vitals Window.
  [Note: The most recent set of vitals is determined by the last record listed in the Vitals tab (most recent date entered in the 'Date Measured' field located in the Vital's Window).]

• Height: This will display the Height as found under the 'Height/Length' column of the most recent set of vital signs entered in the Vitals table located in Patients > Clinical > Vitals. This data will pull from the 'Length/Height' field located in the selected entry's Vitals Window.
  [Note: The most recent set of vitals is determined by the last record listed in the Vitals tab (most recent date entered in the 'Date Measured' field located in the Vital's Window).]

• Home Phone: This will reflect the data as entered in a 'Number' field located in Patients > Patient.
  [Note: The 'Number' field's adjoining 'Type' popup MUST be set to "Home Phone".]

• Home Phone Extension: This will reflect the data as entered in an 'Ext' field located in Patients > Patient.
  [Note: The 'Ext' field's adjoining 'Type' popup MUST be set to "Home Phone".]

• Hygienist First Name: This will display the First Name of the hygienist selected from the 'Preferred Hygienist' popup located in Patients > Patient. This data will pull from the 'First' field located in the selected hygienist's Reference.

• Hygienist ID: This will display the User ID of the hygienist selected from the 'Preferred Hygienist' popup located in Patients > Patient. This data will pull from the 'User ID' field located in the selected hygienist's Reference.

• Hygienist Last Name: This will display the Last Name of the hygienist selected from the 'Preferred Hygienist' popup located in Patients > Patient. This data will pull from the 'Last' field located in the selected hygienist's Reference.

• Hygienist Middle Name: This will display the Middle Name of the hygienist selected from the 'Preferred Hygienist' popup located in Patients > Patient. This data will pull from the 'Middle' field located in the selected hygienist's Reference.

• Is Employed: This is a "True/False" pull field that will display an 'X' respective to having selected "Employed", "Self-Employed", or "Active Military" from the 'Employment' popup located in Patients > Patient.
  [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when any of these items are selected. If formatted for "False" an 'X' will display when none of these items are selected.]

• Is Female: This is a "True/False" pull field that will display an 'X' respective to having selected "Female" from the 'Sex' popup located in Patients > Patient.
  [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Female" is selected. If formatted for "False" an 'X' will display when "Male" is selected.]

• Is Full Time Student: This is a "True/False" pull field that will display an 'X' respective to having selected "Full-Time Student" from the 'Employment' popup located in Patients > Patient.
  [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Full-Time Student" is selected. If formatted for "False" an 'X' will display when "Full-Time Student" is not selected.]

• Is Male: This is a "True/False" pull field that will display an 'X' respective to having selected "Male" from the 'Sex' popup located in Patients > Patient.
  [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Male" is selected. If formatted for "False" an 'X' will display when "Female" is selected.]

• Is Marital Status Other: This is a "True/False" pull field that will display an 'X' respective to having selected "Legally Separated", "Divorced", "Widowed", "Unknown", or "Partner" from the 'Marital Status' popup located in Patients > Patient.
  [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when any of these items are selected. If formatted for "False" an 'X' will display when none of these items are selected.]

• Is Married: This is a "True/False" pull field that will display an 'X' respective to having selected "Married" from the 'Marital Status' popup located in Patients > Patient.
  [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Married" is selected. If formatted for "False" an 'X' will display when "Married" is not selected.]

• Is Part Time Student: This is a "True/False" pull field that will display an 'X' respective to having selected "Part-Time Student" from the 'Employment' popup located in Patients > Patient.
  [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Part-Time Student" is selected. If formatted for "False" an 'X' will display when "Part-Time Student" is not selected.]

• Is Single: This is a "True/False" pull field that will display an 'X' respective to having selected "Single" from the 'Marital Status' popup located in Patients > Patient.
  [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Single" is selected. If formatted for "False" an 'X' will display when "Single" is not selected.]

• Last Appointment: This will display the date of the patient's most recent past appointment, starting with the current date.

• Last Appointment Time: This will display the Appointment Start Time of the patient's most recent past appointment, starting with the current date.

• Last Visit: This will reflect the Procedure Date as entered in the 'Procedure Date' field located in the Charge Window of most recent charge on the patient's ledger.

• Marital Status (S/M/X/D/W/P/U): This will display a letter respective to having selected "Single (S)", "Married (M)", "Legally Separated (X)", "Divorced (D)", "Widowed (W)", "Partner (P)", or "Unknown (U)" from the 'Marital Status' popup located in Patients > Patient.

• Medicare Expiration: This will reflect the date as entered in the 'Medicare Expiration' field located in Patients > Patient.
  [Note: "Medicare" MUST be selected from the 'SSN/Medicare' popup located in Preferences > Localization.]

• Mobile Phone: This will reflect the data as entered in a 'Number' field located in Patients > Patient.
  [Note: The 'Number' field's adjoining 'Type' popup MUST be set to "Mobile Phone".]

• Mobile Phone Extension: This will reflect the data as entered in an 'Ext' field located in Patients > Patient.
  [Note: The 'Ext' field's adjoining 'Type' popup MUST be set to "Mobile Phone".]

• Name: This will reflect the data as entered in the 'First Name', 'Middle Name', and 'Last Name' fields located in Patients > Patient.
  [Note: This pull field will display the data as "first name, middle initial, last name (John X. Doe).]

• Name (Last, First Mi): This will reflect the data as entered in the 'First Name', 'Middle Name', and 'Last Name' fields located in Patients > Patient.
  [Note: This pull field will display the data as "last name, first name, middle initial (Doe, John X.).]

• Name, First: This will reflect the data as entered in the 'First Name' field located in Patients > Patient.

• Name, Last: This will reflect the data as entered in the 'Last Name' field located in Patients > Patient.

• Name, Maiden: This will reflect the data as entered in the 'Maiden Name' field located in Patients > Patient.

• Name, Middle: This will reflect the data as entered in the 'Middle Name' field located in Patients > Patient.

• Name, Nickname: This will reflect the data as entered in the 'Nickname' field located in Patients > Patient.

• Name, Prefix: This will reflect the data as entered in the 'Prefix' field located in Patients > Patient.

• Name, Suffix: This will reflect the data as entered in the 'Suffix' field located in Patients > Patient.

• New Patient Date: This will reflect the date as entered in the 'New Patient Date' located in Patients > Patient.

• Next Appointment: This will display the Appointment Date of the patient's next scheduled appointment in the future excluding the current date.

• Next Appointment Time: This will display the Appointment Start Time of the patient's next scheduled appointment in the future, excluding the current date.

• Notes: This will reflect the data as entered in the 'Notes' field located Patients > Patient > Notes.

• Office ID: This will display the Office ID of the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'Office ID' field located in the selected office's Reference.

• Office Name: This will display the Name of the office selected from the 'Office' popup located in Patients > Patient. This data will pull from the 'Office Name' field located in the selected office's Reference.
  [Note: This field is inaccessible and MUST be changed or updated through the Accounting Department.]

• Other Phone: This will reflect the data as entered in a 'Number' field located in Patients > Patient.
  [Note: The 'Number' field's adjoining 'Type' popup MUST be set to "Other Phone".]

• Other Phone Extension: This will reflect the data as entered in an 'Ext' field located in Patients > Patient.
  [Note: The 'Ext' field's adjoining 'Type' popup MUST be set to "Other Phone".]

• Patient Balance 120 Days: This will display the total past due Account Balance for any charges that are between 121 and 150 days old.
  [Note: Aging is determined starting from the procedure date.]

• Patient Balance 120 Plus Days: This will display the total past due Account Balance for any open charges that are over 120 days old.
  [Note: Aging is determined starting from the procedure date.]

• Patient Balance 150 Plus Days: This will display the total past due Account Balance for any open charges that are over 150 days old.
  [Note: Aging is determined starting from the procedure date.]

• Patient Balance 30 Days: This will display the total past due Account Balance for any open charges that are between 31 and 60 days old.
  [Note: Aging is determined starting from the procedure date.]

• Patient Balance 60 Days: This will display the total past due Account Balance for any open charges that are between 61 and 90 days old.
  [Note: Aging is determined starting from the procedure date.]

• Patient Balance 90 Days: This will display the total past due Account Balance for any open charges that are between 91 and 120 days old.
  [Note: Aging is determined starting from the procedure date.]

• Patient Balance Current: This will display the total Account Balance for any open charges that are between 1 and 30 days old.
  [Note: Aging is determined starting from the procedure date.]

• Patient Balance Total: This will display the total Account Balance.

• Patient Portion Balance 120 Days: This will display the total past due Patient Portion balance for any charges that are between 121 and 150 days old.
  [Note: Aging is determined starting from the procedure date.]

• Patient Portion Balance 120 Plus Days: This will display the total past due Patient Portion balance for any open charges that are over 120 days old.
  [Note: Aging is determined starting from the procedure date.]

• Patient Portion Balance 150 Plus Days: This will display the total past due Patient Portion balance for any open charges that are over 150 days old.
  [Note: Aging is determined starting from the procedure date.]

• Patient Portion Balance 30 Days: This will display the total past due Patient Portion balance for any open charges that are between 31 and 60 days old.
  [Note: Aging is determined starting from the procedure date.]

• Patient Portion Balance 60 Days: This will display the total past due Patient Portion balance for any open charges that are between 61 and 90 days old.
  [Note: Aging is determined starting from the procedure date.]

• Patient Portion Balance 90 Days: This will display the total past due Patient Portion balance for any open charges that are between 91 and 120 days old.
  [Note: Aging is determined starting from the procedure date.]

• Patient Portion Balance Current: This will display the total Patient Portion balance for any open charges that are between 1 and 30 days old.
  [Note: Aging is determined starting from the procedure date.]

• Patient Portion Balance Total: This will display the total Patient Portion balance.

• Patients Recent Image: This will display the selected patient's most recent Patient Photo located in Attachments > Patient Photos.
  [Note: The patient's photos may also be found in the Patient Photo popup button located below the sidebar.]

• Preferred Language: This will reflect the Language as selected from the 'Preferred Language' popup located in Patients > Patient.

• Primary Relationship: This will reflect the Relationship as selected from the 'Relationship to Primary' popup located in Patients > Patient.

• Provider First Name: This will display the First Name of the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'First' field located in the selected provider's User Reference.

• Provider ID: This will display the Provider ID of the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'User ID' field located in the selected provider's User Reference > User Information.

• Provider Last Name: This will display the Last Name of the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'Last' field located in the selected provider's User Reference.

• Provider Middle Name: This will display the Middle Name of the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'Middle' field located in the selected provider's User Reference.

• Provider Prof. Title: This will display the Professional Title of the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'Professional Title' field located in the selected provider's User Reference.

• Race: This will display any Race listed in Patients > Patient > Race/Ethnicity.
  [Note: The order of the listed races is determined by dragging and dropping the entries into the desired order.]

• Respiration: This will display the Respiration Rate as found under the 'Respiration Rate' column of the most recent set of vital signs entered in the Vitals table located in Patients > Clinical > Vitals. This data will pull from the 'Respiration rate' field located in the selected entry's Vitals Window.
  [Note: The most recent set of vitals is determined by the last record listed in the Vitals tab (most recent date entered in the 'Date Measured' field located in the Vital's Window).]

• SPO2: This will display the Peripheral Capillary Oxygen Saturation as found under the 'Sp 02' column  of the most recent set of vital signs entered in the Vitals table located in Patients > Clinical > Vitals. This data will pull from the 'Sp 02' field located in the selected entry's Vitals Window.
  [Note: The most recent set of vitals is determined by the last record listed in the Vitals tab (most recent date entered in the 'Date Measured' field located in the Vital's Window).]

• SSN: This will reflect the data as entered in the 'Social Security' field located in Patients > Patient.

• SSN Last 4: This will reflect last 4 digits of the SSN as entered in the 'Social Security' filed located in Patients > Patient.

• School City: This will reflect the data as entered in the 'City' field located in Patients > Patient > CDA.
  [Note: The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization.]

• School Name: This will reflect the data as entered in the 'School Name' field located in Patients > Patient > CDA.
  [Note: The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization.]

• School State: This will reflect the data as entered in the 'State' field located in Patients > Patient > CDA.
  [Note: The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization.]

• School Street Address: This will reflect the data as entered in the 'Street Address' field located in Patients > Patient > CDA.
  [Note: The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization.]

• School Suite: This will reflect the data as entered in the 'Suite/Apt #' field located in Patients > Patient > CDA.
  [Note: The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization.]

• School Zip Code: This will reflect the data as entered in the 'Zip/Postal Code' field located in Patients > Patient > CDA.
  [Note: The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization.]

• Secondary Relationship: This will reflect the relationship as selected from the 'Relationship to Secondary' popup located in Patients > Patient.

• Sex: This will display a numeric code reflective of the data selected from the 'Sex' popup located in Patients > Patient.

  • Male: 0

  • Female: 1

  • Unknown: 2

• Sex (M/F): This will display an 'M' or an 'F' respective to having selected "Male" or "Female" from the 'Sex' popup located in Patients > Patient.

• Sex (male/female): This will display "male" or "female" respective to having selected "Male" or "Female" from the 'Sex' popup located in Patients > Patient.

• Smoking Quit Date: This will reflect the date as displayed in the 'Quit Date' column of the first status listed in Patients > Clinical > Smoking. This data will pull from the 'End Date' field located in the selected entry's Smoking Status Window.
  [Note: The first smoking status listed is determined by the most recent smoking status entry or update.]

• Smoking Start Date: This will reflect the date as displayed in the 'Start Date' column of the first status listed in Patients > Clinical > Smoking. This data will pull from the 'Start Date' field located in the selected entry's Smoking Status Window.
  [Note: The first smoking status listed is determined by the most recent smoking status entry or update.]

• Smoking Status: This will reflect the data as displayed in the 'Smoking Status' column of the first status listed in Patients > Clinical > Smoking. This data will pull from the 'Smoking Status' popup located in the selected entry's Smoking Status Window.
  [Note: The first smoking status listed is determined by the most recent smoking status entry or update.]

• Smoking Status Updated: This will reflect the date as displayed in the 'Start Date' column of the most recently updated entry listed in Patients > Clinical > Smoking.
  [Note: The first smoking status listed is determined is by the most recent smoking status entry or update.]

• Temperature: This will display the Body Temperature as found under the 'Temperature' column of the most recent set of vital signs entered in the Vitals t located in Patients > Clinical > Vitals. This data will pull from the 'Temp' field located in the selected entry's Vitals Window.
  [Note: The most recent set of vitals is determined by the last record listed in the Vitals tab (most recent date entered in the 'Date Measured' field located in the Vital's Window).]

• Weight: This will display the Weight as found under the 'Weight' column of the most recent set of vital signs entered in the Vitals table located in Patients > Clinical > Vitals. This data will pull from the 'Weight' field located in the selected entry's Vitals Window.
  [Note: The most recent set of vitals is determined by the last record listed in the Vitals tab (most recent date entered in the 'Date Measured' field located in the Vital's Window).]

• Work Phone: This will reflect the data as entered in a 'Number' field located in Patients > Patient.
  [Note: The 'Number' field's adjoining 'Type' popup MUST be set to "Work Phone".]

• Work Phone Extension: This will reflect the data as entered in an 'Ext' field located in Patients > Patient.
  [Note: The 'Ext' field's adjoining 'Type' popup MUST be set to "Work Phone".]

Patient AllergiesNumber of items to display and row offset determined by Form Rules.
[Note: Default Form Rules: Max Items - 1; Row Offset - 0.00]

• Allergy: This will display the Allergy Description as found under the 'Allergy' column for any active Allergy record as listed in Patients > Clinical > Allergy.
  [Note: The order of the listed allergies is determined by dragging and dropping the entries into the desired order when the 'Allergy' popup is set to "All".]

• Allergy Date Last Checked: This will reflect the date as entered in the 'Last' field located in Patients > Clinical > Allergy.

• Allergy Identified Date: This will reflect the date as entered in the 'Identified Date' field for any active Allergy record listed in Patients > Clinical > Allergy.
  [Note: The order of the listed allergies is determined by dragging and dropping the entries into the desired order when the 'Allergy' popup is set to "All".]

• Allergy Note: This will reflect the data as entered in any 'Notes' field for any active Allergy record listed in Patients > Clinical > Allergy.
  [Note: The order of the listed allergies is determined by dragging and dropping the entries into the desired order when the 'Allergy' popup is set to "All".]

• Allergy Reaction: This will reflect the data as entered in any 'Reactions Description' field for any active Allergy record listed in Patients > Clinical > Allergy.
  [Note: The order of the listed allergies is determined by dragging and dropping the entries into the desired order when the 'Allergy' popup is set to "All".]

• Allergy Severity: This will reflect the data as selected from any 'Severity' popup for any active Allergy record listed in Patients > Clinical > Allergy.
  [Note: The order of the listed allergies is determined by dragging and dropping the entries into the desired order when the 'Allergy' popup is set to "All".]

• Allergy Status: This will reflect the data as selected from any 'Status' popup for any active Allergy record listed in Patients > Clinical > Allergy.
  [Note: The order of the listed allergies is determined by dragging and dropping the entries into the desired order when the 'Allergy' popup is set to "All".]

 Primary Guarantor

• Address, City: This will reflect the data as entered in the 'City' field located in Patients > Primary.

• Address Country: This will reflect the data as entered in the 'Country' field located in Patients > Primary.

• Address, State: This will reflect the data as entered in the 'State' field located in Patients > Primary.

• Address, Street: This will reflect the data as entered in the 'Street Address' field located in Patients > Primary.

• Address, Suite/Apt#: This will reflect the data as entered in the 'Suite/Apt. Number' field located in Patients > Primary.

• Address, Zip Code: This will reflect the data as entered in the 'Zip Code' field located in Patients > Primary.

• Age: This will display the Age of the primary guarantor as determined by the date of birth as entered in the 'Birth Date' field located in Patients > Primary.

• Birthday: This will reflect the date as entered in the 'Birth Date' field located in Patients > Primary.

• Email: This will reflect the data as entered in the 'Email' field located in Patients > Primary.

• Employer City: This will display the City of the first Employer record listed in the Employers table located in Patients > Primary. This data will pull from the 'City' filed located in the selected Employer's Reference.

• Employer Group Number: This will reflect the data as entered in the 'Group #' field of the first Employer record listed in the Employers table located in Patients > Primary.

• Employer Name: This will display the Name of the first Employer record listed in the Employers table located in Patients > Primary. This data will pull from the 'Employer Name' filed located in the selected employer's Reference.

• Employer Phone: This will display the Phone Number of the first Employer record listed in the Employers table located in Patients > Primary. This data will pull from the 'Phone' field located in the selected employer's Reference.

• Employer Phone Extension: This will reflect the data as entered in the 'Extension' field of the first Employer record listed in the Employers table located in Patients > Primary.

• Employer State: This will display the State of the first Employer record listed in the Employers table located in Patients > Primary. This data will pull from the 'State' field located in the selected employer's Reference.

• Employer Street Address: This will display the Street Address of the first Employer record listed in the Employers table located in Patients > Primary. This data will pull from the 'Street Address' field located in the selected employer's Reference.

• Employer Suite: This will display the Suite Number of the first Employer record listed in the Employers table located in Patients > Primary. This data will pull from the 'Suite' field located in the selected employer's Reference.

• Employer Zip Code: This will display the Zip Code of the first Employer record listed in the Employers table located in Patients > Primary. This data will pull from the 'Zip Code' field located in the selected employer's Reference.

• Home Phone: This will reflect the data as entered in a 'Phone' field located in Patients > Primary.
  [Note: The 'Phone' field's adjoining 'Type' popup MUST be set to "Home Phone".]

• Home Phone Extension: This will reflect the data as entered in an 'Ext' field located in Patients > Primary.
  [Note: The 'Ext' field's adjoining 'Type' popup MUST be set to "Home Phone".]

• Mobile Phone: This will reflect the data as entered in a 'Phone' field located in Patients > Primary.
  [Note: The 'Phone' field's adjoining 'Type' popup MUST be set to "Mobile Phone".]

• Mobile Phone Extension: This will reflect the data as entered in an 'Ext' field located in Patients > Primary.
  [Note: The 'Ext' field's adjoining 'Type' popup MUST be set to "Mobile Phone".]

• Name, First: This will reflect the data as entered in the 'First Name' field located in Patients > Primary.

• Name, Last: This will reflect the data as entered in the 'Last Name (Guarantor)' field located in Patients > Primary.

• Name, Maiden: This will reflect the data as entered in the 'Maiden Name' field located in Patients > Primary.

• Name, Middle: This will reflect the data as entered in the 'Middle' field located in Patients > Primary.

• Name, Nickname: This will reflect the data as entered in the 'Nickname' field located in Patients > Primary.

• Name, Prefix: This will reflect the data as entered in the 'Prefix' field located in Patients > Primary.

• Name, Suffix: This will reflect the data as entered in the 'Suffix' field located in Patients > Primary.

• Other Phone: This will reflect the data as entered in a 'Phone' field located in Patients > Primary.
  [Note: The 'Phone' field's adjoining 'Type' popup MUST be set to "Other Phone".]

• Other Phone Extension: This will reflect the data as entered in an 'Ext' field located in Patients > Primary.
  [Note: The 'Ext' field's adjoining 'Type' popup MUST be set to "Other Phone".]

• Release Of Information: This is a "True/False" pull field that will display an 'X' respective to having selected the 'Release of Info (box 12)' ('Release of Info (box 36)' in DDS) checkbox located in Patients > Primary.
  [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when the checkbox is selected. If formatted for "False" an 'X' will display when the checkbox is not selected.]

• SSN: This will reflect the data as entered in the 'Social Security' field located in Patients > Primary.

• SSN Last 4: This will reflect the last four digits of the Social Security Number as entered in the 'Social Security' field located in Patients > Primary.

• Sex M/F: This will display an 'M' or an 'F' respective to having selected "Male" or "Female" from the 'Sex' popup located in Patients > Primary.

• Sex male/female: This will display an 'M' or an 'F' respective to having selected "Male" or "Female" from the 'Sex' popup located in Patients > Primary.

• Signature On File: This is a "True/False" pull field that will display an 'X' respective to having selected 'Signature on File (box 13)' ('Signature on File (box 37)' in DDS) checkbox located in Patients > Primary.
  [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when the checkbox is selected. If formatted for "False" an 'X' will display when the checkbox is not selected.]

• Work Phone: This will reflect the data as entered in a 'Phone' field located in Patients > Primary.
  [Note: The 'Phone' field's adjoining 'Type' popup MUST be set to "Work Phone".]

• Work Phone Extension: This will reflect the data as entered in an 'Ext' field located in Patients > Primary.
  [Note: The 'Ext' field's adjoining 'Type' popup MUST be set to "Work Phone".]

Primary Insurance 

• Copay: This will reflect the data as entered in the 'Copay' field found in the patient's Primary Insurance Carrier located in Patients > Patient > Insurance.
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Division/Section Number: This will display the Division/Section Number of the patient's Primary insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Division/Section' field of the selected Carrier's record found in the Insurance table located in Patients > Primary or Secondary (dependent upon patient's Primary Insurance Carrier).
  [Note: 1) The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Employer Address: This will display the Street Address of the employer selected from the 'Employer' popup found in the patient's Primary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Primary Insurance Carrier). This data will pull from the 'Street Address' field located in the selected employer's Reference.
  [Note: 1) An Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance.]

• Employer City: This will display the City of the employer selected from the 'Employer' popup found in the patient's Primary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Primary Insurance Carrier). This data will pull from the 'City' field located in the selected employer's Reference.
  [Note: 1) An Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance.]

• Employer Extension: This will display the Phone Extension of the employer selected from the 'Employer' popup found in the patient's Primary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Primary Insurance Carrier). This data will pull from the 'Extension' field located in the selected employer's Reference.
  [Note: 1) An Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance.]

• Employer Group Number: This will display the Group Number of the employer selected from the 'Employer' popup found in the patient's Primary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Primary Insurance Carrier). This data will pull from the 'Group #' field located in the selected employer's Reference.
  [Note: 1) An Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance.]

• Employer Name: This will display the Name of the employer selected from the 'Employer' popup found in the patient's Primary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Primary Insurance Carrier). This data will pull from the 'Employer Name' field located in the selected employer's Reference.
  [Note: 1) An Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance.]

• Employer Phone: This will display the Phone Number of the employer selected from the 'Employer' popup found in the patient's Primary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Primary Insurance Carrier). This data will pull from the 'Phone' field located in the selected employer's Reference.
  [Note: 1) An Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance.]

• Employer State: This will display the State of the employer selected from the 'Employer' popup found in the patient's Primary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Primary Insurance Carrier). This data will pull from the 'State' field located in the selected employer's Reference.
  [Note: 1) An Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance.]

• Employer Suite: This will display the Suite Number of the employer selected from the 'Employer' popup found in the patient's Primary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Primary Insurance Carrier). This data will pull from the 'Suite' field located in the selected employer's Reference.
  [Note: 1) TAn Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance.]

• Employer Zip Code: This will display the Zip Code of the employer selected from the 'Employer' popup found in the patient's Primary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Primary Insurance Carrier). This data will pull from the 'Zip Code' field located in the selected employer's Reference.
  [Note: 1) An Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance.]

• End Date: This will display the End Date of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'End Date' field found in the Insurance table located in Patients > Primary or Secondary (dependent upon patient's Primary Insurance Carrier).
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Group Number: This will display the Group Number for the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Group #' field found in the selected Carrier's record located in Patients > Primary or Secondary (dependent upon patient's Primary Insurance Carrier).
  [Note: 1) When the Primary Insurance record has an employer selected for the 'Employer' popup, this data will instead pull from the 'Group #' field located in the selected employer's record. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance.]

• Insurance Carrier: This will display the Name of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Insurance Company' field located in the selected carrier's Reference > Company Info.
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Insurance City: This will display the City of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'City' field located in the selected carrier's Reference > Company Info.
  [Note: 1) If the patient's Primary Insurance record is tied to an insurance plan, this data will instead pull from the 'City' field located in the selected carrier's Reference > Plans > Demographic. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Insurance Contact Person: This will display the Name of the contact person for the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Contact Person' field located in the selected carrier's Reference > Company Info.
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Insurance Fax Number: This will display the Fax Number of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Contact Person' field located in the selected carrier's Reference > Company Info.
  [Note: 1) If the patient's Primary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Demographic. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Insurance Has Prior Authorization: This is a "True/False" pull field that will display an 'X' respective to having selected the patient's Primary Insurance Carrier from the 'Insurance' popup for any Prior Authorization record added to the Prior Authorization table located in Patients > Ledger > Incident Menu > Prior Auth.
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance. 2) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when a prior auth. is selected. If formatted for "False", an 'X' will display when a prior auth. is not selected.]

• Insurance Is ChampVA: This is a "True/False" pull field that will display an 'X' respective to having selected 'Veterans Administration Plan' from the 'Plan' popup located in the patient's Primary Insurance Carrier's Reference > Claims.
  [Note: 1) If the patient's Primary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance. 3) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected.]

• Insurance is Champus: This is a "True/False" pull field that will display an 'X' respective to having selected 'Champus' from the 'Plan' popup located in the patient's Primary insurance Carrier's Reference > Claims.
  [Note: 1) If the Primary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance. 3) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected]

• Insurance is FECA: This is a "True/False" pull field that will display an 'X' respective to having selected 'Other Federal Program' from the 'Plan' popup located in the patient's Primary Insurance Carrier's Reference > Claims.
  [Note: 1) If the patient's Primary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance. 3) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected

• Insurance is Group Health Plan: This is a "True/False" pull field that will display an 'X' respective to having selected 'Preferred Provider Organization (PPO)/Exclusive Provider Organization (EPO)/Health Maintenance Organization (HMO)' from the 'Plan' popup located in the patient's Primary Insurance Carrier's Reference > Claims.
  [Note: 1) If the patient's Primary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance. 3) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected]

• Insurance is Medicaid: This is a "True/False" pull field that will display an 'X' respective to having selected 'Medicaid' from the 'Plan' popup located in the patient's Primary Insurance Carrier's Reference > Claims.
  [Note: 1) If the patient's Primary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance. 3) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected]

• Insurance is Medicare: This is a "True/False" pull field that will display an 'X' respective to having selected 'Medicare Part B' from the 'Plan' popup located in the patient's Primary Insurance Carrier's Reference > Claims.
  [Note: 1) If the patient's Primary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) The patient's primary insurance carrier is determined by the first Insurance record listed in Patients > Patient > Insurance. 3) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected]

• Insurance is Other Plan Type: This is a "True/False" pull field that will display an 'X' respective to having selected 'Self-pay/Central Certification/Other Non-Federal Programs/Point of Service(POS)/Indemnity Insurance/HMO Medicare Risk/Automobile Medical/Blue Cross / Blue Shield/Commercial Insurance Co./Disability/Liability/Liability Medical/Title V/Workers Compensation Health Claim/Mutually Defined Unknown' from the 'Plan' popup located in the patient's Primary Insurance Carrier's Reference > Claims.
  [Note: 1) If the patient's Primary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance. 3) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected]

• Insurance Phone: This will display the Phone Number of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Phone' field located in the selected carrier's Reference > Company Info.
  [Note: 1) If the patient's Primary Insurance record is tied to an insurance plan, this data will instead pull from the 'Phone' field located in the selected carrier's Reference > Plans > Demographic. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Insurance Phone Extension: This will display the Extension number of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Extension' field located in the selected carrier's Reference > Company Info.
  [Note: 1) If the patient's Primary Insurance record is tied to an insurance plan, this data will instead pull from the 'Phone' field located in the selected carrier's Reference > Plans > Demographic. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Insurance Plan Contact Person: This will display the Name of the contact person for the insurance plan selected from the 'Plan' popup found in the patient's Primary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Primary Insurance Carrier). This data will pull from the 'Contact Person' field located in the selected carrier's Reference > Plans > Demographic.
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance.]

• Insurance Plan Name: This will display the Name of the insurance plan selected from the 'Plan' popup found in the patient's Primary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Primary Insurance Carrier). This data will pull from the 'Plan Name' field found in the Insurance Plan table located in the selected carrier's Reference > Plans.
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance.]

• Insurance Plan Note: This will display the Notes for the insurance plan selected from the 'Plan' popup found in the patient's Primary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Primary Insurance Carrier). This data will pull from the 'Notes' field located in the selected carrier's Reference > Plans > Notes.
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance.]

• Insurance Plan Type: This will display the Plan Type for the insurance plan selected from the 'Plan Type' popup found in the patient's Primary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Primary Insurance Carrier). This data will pull from the 'Plan' popup located in the selected carrier's Reference > Claims.
  [Note: 1) If the patient's Primary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance.]

• Insurance Prior Auth Exp Date: This will reflect the date as entered in the 'Expiration Date' field found in the oldest active Prior Authorization record located in Patients > Patient > Incident Menu > Prior Auth. for the patient's most recent incident (dependent upon the patient's Primary Insurance Carrier being selected from the Prior Auth record's 'Insurance' popup).
  [Note: 1) The oldest active Prior Authorization record is located at the bottom of the list WITH remaining visits located in the Prior Auth tab. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance.]

• Insurance Prior Auth Start Date: This will reflect the date as entered in the 'Start Date' filed found in the oldest active Prior Authorization record located in Patients > Patient > Incident Menu > Prior Auth. for the patient's most recent incident (dependent upon the patient's Primary Insurance Carrier being selected from the Prior Auth record's 'Insurance' popup).
  [Note: 1) The oldest active Prior Authorization record is located at the bottom of the list WITH remaining visits located in the Prior Auth tab. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance.]

• Insurance Prior Auth Total Visits: This will reflect the data as entered in the 'Total Visits' field found in the oldest active Prior Authorization record located in Patients > Patient > Incident Menu > Prior Auth. for the patient's most recent incident (dependent upon the patient's Primary Insurance Carrier being selected from the Prior Auth record's 'Insurance' popup).
  [Note: 1) The oldest active Prior Authorization record is located at the bottom of the list WITH remaining visits located in the Prior Auth tab. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance.]

• Insurance Prior Auth Visits Remain: This will reflect the data as entered the 'Remaining Visits' field found in the oldest active Prior Authorization record located in Patients > Patient > Incident Menu > Prior Auth. for the patient's most recent incident (dependent upon the patient's Primary Insurance Carrier being selected from the Prior Auth record's 'Insurance' popup).
  [Note: 1) The oldest active Prior Authorization record is located at the bottom of the list WITH remaining visits located in the Prior Auth tab. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance.]

• Insurance Prior Authorization: This will reflect the data as entered in the 'Prior Authorization' field found in the oldest active Prior Authorization record located in Patients > Patient > Incident Menu > Prior Auth. for the patient's most recent incident (dependent upon the patient's Primary Insurance Carrier being selected from the Prior Auth record's 'Insurance' popup).
  [Note: 1) The oldest active Prior Authorization record is located at the bottom of the list WITH remaining visits located in the Prior Auth tab. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance.]

• Insurance State: This will display the State of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'State' field located in the selected carrier's Reference > Company Info.
  [Note: 1) If the patient's Primary Insurance record is tied to an insurance plan, this data will instead pull from the 'State' field located in the selected carrier's Reference > Plans > Demographic. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Insurance Street Address: This will display the Street Address of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Street Address' field located in the selected carrier's Reference > Company Info.
  [Note: 1) If the patient's Primary Insurance record is tied to an insurance plan, this data will instead pull from the 'Street Address' field located in the selected carrier's Reference > Plans > Demographic. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Insurance Suite: This will display the Suite Number of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Suite' field located in the selected carrier's Reference > Company Info.
  [Note: 1) If the patient's Primary Insurance record is tied to an insurance plan, this data will instead pull from the 'suite' field located in the selected carrier's Reference > Plans > Demographic. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Insurance Zip Code: This will display the Zip Code of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Zip Code' field located in the selected carrier's Reference > Company Info.
  [Note: 1) If the patient's Primary Insurance record is tied to an insurance plan, this data will instead pull from the 'Zip Code' field located in the selected carrier's Reference > Plans > Demographic. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Item Description: [Nonfunctional]

• Patient Subscriber Number: This will reflect the data as entered in the 'Subscriber #' field found in the patient's Primary Insurance Carrier record located in Patients > Patient > Insurance.
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Person Subscriber Number: This will display the Subscriber Number of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Subscriber #' field found in the selected carrier's record located in Patients > Primary or Secondary (dependent upon patient's Primary Insurance Carrier).
  [Note: 1) The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Policy Holder City: This will display the City for the policy holder of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'City' field located in Patients > Primary or Secondary (dependent upon the patient's Primary Insurance Carrier).
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Policy Holder Country: This will display the Country for the policy holder of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Country' field located in Patients > Primary or Secondary (dependent upon the patient's Primary Insurance Carrier).
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Policy Holder Date of Birth: This will display the Date of Birth for the policy holder of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Birth Date' field located in Patients > Primary or Secondary (dependent upon the patient's Primary Insurance Carrier).
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Policy Holder First Name: This will display the First Name for the policy holder of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'First Name' field located in Patients > Primary or Secondary (dependent upon the patient's Primary Insurance Carrier).
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Policy Holder Home Phone: This will display the Home Phone Number for the policy holder of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from a 'Phone' field located in Patients > Primary or Secondary (dependent upon the patient's Primary Insurance Carrier).
  [Note: 1) The 'Phone' field's adjoining 'Type' popup MUST be set to "Home Phone". 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Policy Holder Last Name: This will display the Last Name for the policy holder of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Last Name' field located in Patients > Primary or Secondary (dependent upon the patient's Primary Insurance Carrier).
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Policy Holder Middle Name: This will display the Middle Name for the policy holder of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Middle Name' field located in Patients > Primary or Secondary (dependent upon the patient's Primary Insurance Carrier).
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Policy Holder Mobile Phone: This will display the Mobile Phone Number for the policy holder of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from a 'Phone' field located in Patients > Primary or Secondary (dependent upon the patient's Primary Insurance Carrier).
  [Note: 1) The 'Phone' field's adjoining 'Type' popup MUST be set to "Mobile Phone". 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Policy Holder Other Phone: This will display the Other Phone Number for the policy holder of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from a 'Phone' field located in Patients > Primary or Secondary (dependent upon the patient's Primary Insurance Carrier).
  [Note: 1) The 'Phone' field's adjoining 'Type' popup MUST be set to "Other Phone". 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Policy Holder Prefix: This will display the Prefix for the policy holder of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Prefix' field located in Patients > Primary or Secondary (dependent upon the patient's Primary Insurance Carrier).
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Policy Holder SSN: This will display the Social Security Number for the policy holder of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Social Security' field located in Patients > Primary or Secondary (dependent upon the patient's Primary Insurance Carrier).
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Policy Holder SSN Last 4: This will display the last four digits of the Social Security Number for the policy holder of the Primary Insurance Carrier carrier located in Patients > Patient > Insurance. This data will pull from the 'Social Security' field located in Patients > Primary or Secondary (dependent upon the patient's Primary Insurance Carrier).
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Policy Holder State: This will display the State for the policy holder of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Prefix' field located in Patients > Primary or Secondary (dependent upon the patient's Primary Insurance Carrier).
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Policy Holder Street Address: This will display the Street Address for the policy holder of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Street Address' field located in Patients > Primary or Secondary (dependent upon the patient's Primary Insurance Carrier).
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Policy Holder Suffix: This will display the Suffix for the policy holder of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Suffix' field located in Patients > Primary or Secondary (dependent upon the patient's Primary Insurance Carrier).
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Policy Holder Suite: This will display the Suite Number for the policy holder of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Suite' field located in Patients > Primary or Secondary (dependent upon the patient's Primary Insurance Carrier).
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Policy Holder Work Phone: This will display the Work Phone Number for the policy holder of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from a 'Phone' field located in Patients > Primary or Secondary (dependent upon the patient's Primary Insurance Carrier).
  [Note: 1) The 'Phone' field's adjoining 'Type' popup MUST be set to "Work Phone". 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Policy Holder Zip Code: This will display the Zip Code for the policy holder of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Zip Code' field located in Patients > Primary or Secondary (dependent upon the patient's Primary Insurance Carrier).
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Policy Number: This will display the Policy Number of the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Subscriber #' field found in the selected carrier's record located in Patients > Primary or Secondary (dependent upon patient's Primary Insurance Carrier).
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Remaining Coverage: This will reflect the data as displayed/entered in the 'Remaining Coverage' field found in the patient's Primary Insurance Carrier record located in Patients > Patient > Insurance.
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Remaining Deductible: This will reflect the data as displayed/entered in the 'Remaining Coverage' field found in the patient's Primary Insurance Carrier record located in Patients > Patient > Insurance.
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Renewal Date: This will display the Renewal Date for the patient's Primary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Renewal Date' field for the Primary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon the patient's Primary Insurance Carrier).
  [Note: 1) The year will always display as "2008" or "08" due to not being able to enter a year in the 'Renewal Date' field. To avoid this please contact a paper forms specialist. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the patient's Insurance tab.]

• Start Date: This will reflect the date as entered in the 'Start Date' field located in the patient's Primary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Primary Insurance Carrier).
  [Note: The patient's Primary Insurance Carrier is determined by the first Insurance record listed in Patient > Patient > Insurance.]

Primary Procedure Types
Number of items to display and row offset determined by Form Rules.
[Note: Default Form Rules: Max Items - 1; Row Offset - 0.00]

• Procedure Apply Deductible: This is a "True/False" pull field that will display an 'X' respective to having selected the 'Applies to Deductible' checkbox for any procedure type as listed in the Procedure Type table located in the patient's Primary Insurance Carrier's Reference > Plans > Coverage.
  [Note: 1) The patient MUST have an Insurance Plan selected. 1) Procedure Types MUST be added to References > Procedure Types. 2) The patient's Primary Insurance Carrier is determined by the first Insurance record listed in the Insurance table located in Patients > Patient > Insurance. 3) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the checkbox is selected. If formatted for "False", an 'X' will display when the checkbox is deselected.]

• Procedure Coverage Percent: This will reflect the data as entered in any '% Insurance Pays' field as listed in the Procedure Type table located in the patient'sPrimary Insurance Carrier's Reference > Plans > Coverage.
  [Note: 1) The patient MUST have an Insurance Plan selected. 2) Procedure types will NOT display in the Procedure Type table until added to the 'Procedure Types' Reference. 3) The patient's Primary Insurance Carrier's is determined by the first Insurance record listed in Patients > Patient > Insurance.]

• Procedure Type: This will display the Name of any procedure type as listed under the 'Procedure Type' column of the Procedure Type table located in the patient's Primary Insurance Carrier's Reference > Plans > Coverage. This data will pull from the 'Description' field located in the selected procedure type's Reference.
  [Note: 1) The patient MUST have an Insurance Plan selected. 2) Procedure Types MUST be added to References > Procedure Types. 3) The patient's Primary Insurance Carrier is determined by the first Insurance Carrier record listed in Patients > Patient > Insurance.]

Primary Referral

• BCBS: This will display the BCBS Number of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'BCBS' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Blue Cross: This will display the Blue Cross Number of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Blue Cross' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Cell Phone Number: This will display the Cell Phone Number for the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from a 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
  [Note: 1) The 'Phone Number' field's adjoining "phone type" popup MUST be set to "Cell". 2) The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Central Cert: This will display the Central Cert Number of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Central Cert.' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Champus: This will display the Champus Number of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Blue Cross' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• City: This will display the City of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'City' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Commercial: This will display the Commercial Number of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Commercial' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Date: This will reflect the date as entered in the 'Referral Date' field of the patient's Primary Referral located in Patients > Patient > Referrals.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Department: This will display Department for the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Dept.' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Disability: This will display the Disability Number of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Disability' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Email: This will display the Email Address for the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'email' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Expiration Date: This will display the Expiration Date for the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the selected referrer's 'Expiration Date' column and is calculated by adding the month range selected from the 'Months' popup to the Referral Date.
  [Note: 1) The 'Use Referrals Expiration Date' checkbox MUST be selected from References > Localizaion (not available in DDS). 2) When using this field in DDS or selecting 'Indefinite' from the 'Months' popup for other flavors, MacPractice should display the date as 12 months from the Referral date. However it displays the date as the previous month of the same year. 3) The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Expiration Months: This will reflect the data selected from the 'Months' popup found in the patient's Primary Referral record located in Patients > Patient > Referrals.
  [Note: 1) The 'Use Referrals Expiration Date' checkbox MUST be selected from References > Localization. 2) The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Family/Friend: [Nonexistent]

• Fax Number: This will display the Fax Number for the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from a 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
  [Note: 1) The 'Phone Number' field's adjoining "phone type" popup MUST be set to "Fax". 2) The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Federal Employee: This will display the Federal Employee Number of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Federal Employee' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• HMO: This will display the Health Maintenance Organization Number of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'HMO' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Home Phone Number: This will display the Home Phone Number for the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from a 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
  [Note: 1) The 'Phone Number' field's adjoining "phone type" popup MUST be set to "Home". 2) The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Managed Care: This will display the Managed Care Number of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Managed' field located in the selected referral's Reference > Provider IDs.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Medicaid: This will display the Medicaid Number of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Medicaid' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Medicare: This will display the Medicare Number of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Medicare Part B' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Name, First: This will display the First Name of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'First' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's primary referral is determined by the first Referral record listed in the Referrals tab.]

• Name, Last: This will display the Last Name of the patient's primary referral located in Patients > Patient > Referrals. This data will pull from the 'Last' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Name, Middle: This will display the Middle Name of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Middle' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Name, Nickname: This will display the Nickname of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Nickname (AKA)' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Name, Professional Title: This will display the Professional Title of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Prefix' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Name, Suffix: This will display the Suffix of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Suffix' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• National Provider ID: This will display the NPI Number for the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'National Provider ID (NPI)' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

•  Office: This will display the Company Name of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Office/Company' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Other: This will display the Other Non-Federal Number of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Other Non-Federal' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Other Federal: This will display the Other Federal Number of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Other Federal' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• PPO: This will display the PPO Number of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'PPO' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Position Title: This will display the Title/Position of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Title/Position' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Primary Insurance ID: This will display the Primary Insurance ID Number of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Commercial' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• SSN/TID: This will display the Social Security Number/Tax ID for the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'SSN/TID' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Secondary Insurance ID: This will display the Secondary Insurance ID Number of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Commercial' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Self Admin: This will display the Self Admin Number of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Self Admin' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Self Pay: This will display the Self Pay Number of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Self Pay' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• State: This will display the State of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'State' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• State License: This will display the State License Number of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'State License' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Street Address: This will display the Street Address of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Street Address' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Suite: This will display the Suite Number of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Suite' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Taxonomy Code: This will display the Taxonomy/Specialty Code of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Taxonomy (Specialty)' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Tertiary Insurance ID: [Nonfunctional]

• Title V: This will display the Title V Number of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Title V' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Vets Admin: This will display the Vets Admin Number of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Vets Admin.' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Work Phone Number: This will display the Work Phone Number for the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from a 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
  [Note: 1) The 'Phone Number' field's adjoining "phone type" popup MUST be set to "Work". 2) The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Workers Compensation: This will display the Workers Compensation Number of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Workers Compensation.' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.]

• Zip Code: This will display the Zip Code of the patient's Primary Referral located in Patients > Patient > Referrals. This data will pull from the 'Zip Code' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Primary Referral is determined by the first Referral record listed in the Referrals tab.] 

Provider

• ABN Number: This will display the ABN Number for the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'ABN' field located in the selected provider's User Reference > Provider > Additional Credentials.

• CLIA: This will display the CLIA data for the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'CLIA' field located in the selected provider's User Reference > Provider > Claim Credentials.

• DEA Number: This will display the DEA Number for the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'DEA' field located in the selected provider's User Reference > Provider > Additional Credentials.

• DPS Number: This will display the DPS Number for the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'DPS' field located in the selected provider's User Reference > Provider > Additional Credentials.

• Eclaim Tax ID: This is a "True/False" pull field that will display an 'X' respective to having selected "Use Federal ID Number" from the 'Provider Tax ID on Claims' popup located in References > Users > Provider > Claim Credentials for the provider selected from the 'Provider' popup located in Patients > Patient.
  [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when "Use Federal ID Number" is selected. If formatted for "False" an 'X' will display when "Use Social Security Number" is selected.]

• Federal Number: This will display the Federal Number for the provider  selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'Federal' field located in the selected provider's User Reference > Provider > Claim Credentials.

• Form Name: This will display the Form Name data for the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'Name Printed in Box 33 HCFA' (DDS: 'Name Printed in Box 53 of Insurance Form') field located in the selected provider's User Reference > Provider.

• Hospital Number: This will display the Hospital Number for the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull form the 'Hospital' field locate in the selected provider's User Reference > Provider > Additional Credentials.

• ID: This will display the User ID for the provider selected from the 'Provider" popup located in Patients > Patient. This data will pull from the 'User ID' field located in the selected provider's User Reference > User Information.

• Name, First: This will display the First Name of the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'First' field located in the selected provider's User Reference.

• Name, Last: This will display the Last Name of the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'Last' field located in the selected provider's User Reference.

• Name, Middle: This will display the Middle Name of the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'Middle' field located in the selected provider's User Reference.

• Name, Professional Title: This will display the Professional Title for the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'Professional Title' field located in the selected provider's User Reference.

• Name, Suffix: This will display the Suffix for the provider selected from the 'Provider' popup located in thePatients > Patient. This data will pull from the 'Suffix' field located in the selected provider's User Reference.

• National Provider ID: This will display the NPI Number for the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'National Provider ID (NPI)' field located in the selected provider's User Reference > Provider > Claim Credentials.

• Other Number 1: This will display the Other 1 data for the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'Other 1' field located in the selected provider's User Reference > Provider > Additional Credentials.

• Other Number 2: This will display the Other 2 data for the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'Other 2' field located in the selected provider's User Reference > Provider > Additional Credentials.

• Other Number 3: This will display the Other 3 data for the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'Other 3' field located in the selected provider's User Reference > Provider > Additional Credentials.

• Other Number 4: This will display the Other 4 data for the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'Other 4' field located in the selected provider's User Reference > Provider > Additional Credentials.

• Other Number 5: This will display the Other 5 data for the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'Other 5' field located in the selected provider's User Reference > Provider > Additional Credentials.

• Phone: This will display the Phone Number for the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'Phone' field located in the selected provider's User Reference > User Information.

• Phone Extension: This will display the Phone Extension Number for the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'Ext' field located in the selected provider's User Reference > User Information.

• Provider Letter Head: This will display the Professional Title, First Name and Last Name of the provider selected from the 'Provider' popup located in Patients > Patient; followed by the full address of the office selected from the 'Office' popup located in Patients > Patient.  This data will pull from the 'Professional Title', 'First', and 'Last' pull fields located in the selected provider's User Reference, and the 'Street Address', 'Suite', 'City', 'State', and 'Zip Code' fields located in the selected office's Reference.
  [Note: The office fields are inaccessible and can only be changed or updated by the Accounting Department.]

• Provider Number: This will display the Provider Number for the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'Provider' field located in the selected provider's User Reference > Provider > Additional Credentials.

• SSN: This will display the Social Security Number of the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'SSN' field located in the selected provider's User Reference > Provider > Claim Credentials.

• Specialty: This will display the Taxonomy Code for the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'Provider Taxonomy (Specialty)' field located in the selected provider's User Reference > Provider > Claim Credentials.

• State License Number: This will display the State License Number for the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'State License Number' field located in the selected provider's User Reference > Provider > Claim Credentials.

• Sub ID: This will display the Sub ID for the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'Sub ID' field located in the selected provider's User Reference > Provider > Claim Credentials.

• Title XIX Exception Code: This will display the Title XIX Exception Code for the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'Title SA Exception Code Box 25D' field located in the selected provider's User Reference > Provider > Claim Credentials.

• UPIN: This will display the UPIN data for the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'UPIN' field located in the selected provider's User Reference > Provider > Additional Credentials.

• Unique Number: This will display the Unique Number for the provider selected from the 'Provider' popup located in Patients > Patient. This data will pull from the 'Unique' field located in the selected provider's User Reference > Provider > Additional Credentials.

Secondary Guarantor

• Address, City: This will reflect the data as entered in the 'City' field located in Patients > Secondary.

• Address Country: This will reflect the data as entered in the 'Country' field located in Patients > Secondary.

• Address, State: This will reflect the data as entered in the 'State' field located in Patients > Secondary.

• Address, Street: This will reflect the data as entered in the 'Street Address' field located in Patients > Secondary.

• Address, Suite/Apt#: This will reflect the data as entered in the 'Suite/Apt. Number' field located in Patients > Secondary.

• Address, Zip Code: This will reflect the data as entered in the 'Zip Code' field located in Patients > Secondary.

• Age: This will display the Age of the secondary guarantor determined by the date of birth as entered in the 'Birth Date' field located in Patients > Secondary.

• Birthday: This will reflect the date as entered in the 'Birth Date' field located in Patients > Secondary.

• Email: This will reflect the data as entered in the 'Email' field located in Patients > Secondary.

• Employer City: This will display the City of the first Employer record listed in the Employers table located in Patients > Secondary. This data will pull from the 'City' filed located in the selected Employer's Reference.

• Employer Group Number: This will reflect the data as entered in the 'Group #' field of the first Employer record listed in the Employers table located in Patients > Secondary.

• Employer Name: This will display the Name of the first Employer record listed in the Employers table located in Patients > Secondary. This data will pull from the 'Employer Name' filed located in the selected employer's Reference.

• Employer Phone: This will display the Phone Number of the first Employer record listed in the Employers table located in Patients > Secondary. This data will pull from the 'Phone' field located in the selected employer's Reference.

• Employer Phone Extension: This will reflect the data as entered in the 'Extension' field of the first Employer record listed in the Employers table located in Patients > Secondary.

• Employer State: This will display the State of the first Employer record listed in the Employers table located in Patients > Secondary. This data will pull from the 'State' field located in the selected employer's Reference.

• Employer Street Address: This will display the Street Address of the first Employer record listed in the Employers table located in Patients > Secondary. This data will pull from the 'Street Address' field located in the selected employer's Reference.

• Employer Suite: This will display the Suite Number of the first Employer record listed in the Employers table located in Patients > Secondary. This data will pull from the 'Suite' field located in the selected employer's Reference.

• Employer Zip Code: This will display the Zip Code of the first Employer record listed in the Employers table located in Patients > Secondary. This data will pull from the 'Zip Code' field located in the selected employer's Reference.

• Home Phone: This will reflect the data as entered in a 'Phone' field located in Patients > Secondary.
  [Note: The 'Phone' field's adjoining 'Type' popup MUST be set to "Home Phone".]

• Home Phone Extension: This will reflect the data as entered in an 'Ext' field located in Patients > Secondary.
  [Note: The 'Ext' field's adjoining 'Type' popup MUST be set to "Home Phone".]

• Mobile Phone: This will reflect the data as entered in a 'Phone' field located in Patients > Secondary.
  [Note: The 'Phone' field's adjoining 'Type' popup MUST be set to "Mobile Phone".]

• Mobile Phone Extension: This will reflect the data as entered in an 'Ext' field located in Patients > Secondary.
  [Note: The 'Ext' field's adjoining 'Type' popup MUST be set to "Mobile Phone".]

• Name, First: This will reflect the data as entered in the 'First Name' field located in Patients > Secondary.

• Name, Last: This will reflect the data as entered in the 'Last Name (Guarantor)' field located in Patients > Secondary.

• Name, Maiden: This will reflect the data as entered in the 'Maiden Name' field located in Patients > Secondary.

• Name, Middle: This will reflect the data as entered in the 'Middle' field located in Patients > Secondary.

• Name, Prefix: This will reflect the data as entered in the 'Prefix' field located in Patients > Secondary.

• Name, Suffix: This will reflect the data as entered in the 'Suffix' field located in Patients > Secondary.

• Nickname: This will reflect the data as entered in the 'Nickname' field located in Patients > Secondary.

• Other Phone: This will reflect the data as entered in a 'Phone' field located in Patients > Secondary.
  [Note: The 'Phone' field's adjoining 'Type' popup MUST be set to "Other Phone".]

• Other Phone Extension: This will reflect the data as entered in an 'Ext' field located in Patients > Secondary.
  [Note: The adjoining 'Ext' field's 'Type' popup MUST be set to "Other Phone".]

• Release Of Information: This is a "True/False" pull field that will display an 'X' respective to having selected the 'Release of Info (box 12)' checkbox ('Release of Info (box 36)' for DDS) located in Patients > Secondary.
  [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when the checkbox is selected. If formatted for "False" an 'X' will display when the checkbox is not selected.]

• SSN: This will reflect the data as entered in the 'Social Security' field located in Patients > Secondary.

• SSN Last 4: This will reflect the last four digits of the Social Security Number as entered in the 'Social Security' field located in Patients > Secondary.

• Sex M/F: This will display an 'M' or an 'F' respective to having selected "Male" or "Female" from the 'Sex' popup located in Patients > Secondary.

• Sex male/female: This will display an 'M' or an 'F' respective to having selected "Male" or "Female" from the 'Sex' popup located in Patients > Secondary.

• Signature On File: This is a "True/False" pull field that will display an 'X' respective to having selected the 'Signature on File (box 13)' checkbox ('Signature on File (box 37)' for DDS) located in Patients > Secondary.
  [Note: Functionality is dependent upon pull field formatting. If formatted for "True" an 'X' will display when the checkbox is selected. If formatted for "False" an 'X' will display when the checkbox is not selected.]

• Work Phone: This will reflect the data as entered in a 'Phone' field located in Patients > Secondary.
  [Note: The 'Phone' field's adjoining 'Type' popup MUST be set to "Work Phone".]

• Work Phone Extension: This will reflect the data as entered in an 'Ext' field located in Patients > Secondary.
  [Note: The 'Ext' field's adjoining 'Type' popup MUST be set to "Work Phone".]

 Secondary Insurance 

• Copay: This will reflect the data as entered in the 'Copay' field found in the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance.
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Dependent Code: This will reflect the data as entered in the 'Dependent Code' field found in the patient's Secondary Insurance Carrier record located in Patients > Patient > Insurance.
  [Note: 1) The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Division/Section Number: This will display the Division/Section Number of the patient's Secondary insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Division/Section' field of the selected Carrier's record found in the Insurance table located in Patients > Primary or Secondary (dependent upon patient's Secondary Insurance Carrier).
  [Note: 1) The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Employer Address: This will display the Street Address of the employer selected from the 'Employer' popup found in the patient's Secondary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Secondary Insurance Carrier). This data will pull from the 'Street Address' field located in the selected employer's Reference.
  [Note: 1) An Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patients > Patient > Insurance.]

• Employer City: This will display the City of the employer selected from the 'Employer' popup found in the patient's Secondary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Secondary Insurance Carrier). This data will pull from the 'City' field located in the selected employer's Reference.
  [Note: 1) An Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patients > Patient > Insurance.]

• Employer Extension: This will display the Phone Extension of the employer selected from the 'Employer' popup found in the patient's Secondary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Secondary Insurance Carrier). This data will pull from the 'Extension' field located in the selected employer's Reference.
  [Note: 1) An Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patients > Patient > Insurance.]

• Employer Group Number: This will display the Group Number of the employer selected from the 'Employer' popup found in the patient's Secondary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Secondary Insurance Carrier). This data will pull from the 'Group #' field located in the selected employer's Reference.
  [Note: 1) An Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patients > Patient > Insurance.]

• Employer Name: This will display the Name of the employer selected from the 'Employer' popup found in the patient's Secondary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Secondary Insurance Carrier). This data will pull from the 'Employer Name' field located in the selected employer's Reference.
  [Note: 1) An Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patients > Patient > Insurance.]

• Employer Phone: This will display the Phone Number of the employer selected from the 'Employer' popup found in the patient's Secondary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Secondary Insurance Carrier). This data will pull from the 'Phone' field located in the selected employer's Reference.
  [Note: 1) An Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patients > Patient > Insurance.]

• Employer State: This will display the State of the employer selected from the 'Employer' popup found in the patient's Secondary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Secondary Insurance Carrier). This data will pull from the 'State' field located in the selected employer's Reference.
  [Note: 1) An Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patients > Patient > Insurance.]

• Employer Suite: This will display the Suite Number of the employer selected from the 'Employer' popup found in the patient's Secondary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Secondary Insurance Carrier). This data will pull from the 'Suite' field located in the selected employer's Reference.
  [Note: 1) An Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patients > Patient > Insurance.]

• Employer Zip Code: This will display the Zip Code of the employer selected from the 'Employer' popup found in the patient's Secondary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Secondary Insurance Carrier). This data will pull from the 'Zip Code' field located in the selected employer's Reference.
  [Note: 1) An Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patients > Patient > Insurance.]

• End Date: This will display the End Date of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'End Date' field found in the Insurance table located in Patients > Primary or Secondary (dependent upon patient's Secondary Insurance Carrier).
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Group Number: This will display the Group Number for the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Group #' field found in the selected Carrier's record located in Patients > Primary or Secondary (dependent upon patient's Secondary Insurance Carrier).
  [Note: 1) When the Secondary Insurance record has an employer selected for the 'Employer' popup, this data will instead pull from the 'Group #' field located in the selected employer's record. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patients > Patient > Insurance.]

• Insurance Carrier: This will display the Name of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Insurance Company' field located in the selected carrier's Reference > Company Info.
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Insurance City: This will display the City of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'City' field located in the selected carrier's Reference > Company Info.
  [Note: 1) If the patient's Secondary Insurance record is tied to an insurance plan, this data will instead pull from the 'City' field located in the selected carrier's Reference > Plans > Demographic. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Insurance Contact Person: This will display the Name of the contact person for the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Contact Person' field located in the selected carrier's Reference > Company Info.
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Insurance Fax Number: This will display the Fax Number of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Contact Person' field located in the selected carrier's Reference > Company Info.
  [Note: 1) If the patient's Secondary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Demographic. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Insurance Has Prior Authorization: This is a "True/False" pull field that will display an 'X' respective to having selected the patient's Secondary Insurance Carrier from the 'Insurance' popup for any Prior Authorization record added to the Prior Authorization table located in Patients > Ledger > Incident Menu > Prior Auth.
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patients > Patient > Insurance. 2) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when a prior auth. is selected. If formatted for "False", an 'X' will display when a prior auth. is not selected.]

• Insurance Is ChampVA: This is a "True/False" pull field that will display an 'X' respective to having selected 'Veterans Administration Plan' from the 'Plan' popup located in the patient's Secondary Insurance Carrier's Reference > Claims.
  [Note: 1) If the patient's Secondary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patients > Patient > Insurance. 3) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected.]

• Insurance is Champus: This is a "True/False" pull field that will display an 'X' respective to having selected 'Champus' from the 'Plan' popup located in the patient's Secondary insurance Carrier's Reference > Claims.
  [Note: 1) If the Secondary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) The patient's Secondary Insurance Carrier is determined by the first Insurance record listed in Patients > Patient > Insurance. 3) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected]

• Insurance is FECA: This is a "True/False" pull field that will display an 'X' respective to having selected 'Other Federal Program' from the 'Plan' popup located in the patient's Secondary Insurance Carrier's Reference > Claims.
  [Note: 1) If the patient's Secondary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patients > Patient > Insurance. 3) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected

• Insurance is Group Health Plan: This is a "True/False" pull field that will display an 'X' respective to having selected 'Preferred Provider Organization (PPO)/Exclusive Provider Organization (EPO)/Health Maintenance Organization (HMO)' from the 'Plan' popup located in the patient's Secondary Insurance Carrier's Reference > Claims.
  [Note: 1) If the patient's Secondary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patients > Patient > Insurance. 3) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected]

• Insurance is Medicaid: This is a "True/False" pull field that will display an 'X' respective to having selected 'Medicaid' from the 'Plan' popup located in the patient's Secondary Insurance Carrier's Reference > Claims.
  [Note: 1) If the patient's Secondary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patients > Patient > Insurance. 3) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected]

• Insurance is Medicare: This is a "True/False" pull field that will display an 'X' respective to having selected 'Medicare Part B' from the 'Plan' popup located in the patient's Secondary Insurance Carrier's Reference > Claims.
  [Note: 1) If the patient's Secondary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patients > Patient > Insurance. 3) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected]

• Insurance is Other Plan Type: This is a "True/False" pull field that will display an 'X' respective to having selected 'Self-pay/Central Certification/Other Non-Federal Programs/Point of Service(POS)/Indemnity Insurance/HMO Medicare Risk/Automobile Medical/Blue Cross / Blue Shield/Commercial Insurance Co./Disability/Liability/Liability Medical/Title V/Workers Compensation Health Claim/Mutually Defined Unknown' from the 'Plan' popup located in the patient's Secondary Insurance Carrier's Reference > Claims.
  [Note: 1) If the patient's Secondary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patients > Patient > Insurance. 3) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected]

• Insurance Phone: This will display the Phone Number of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Phone' field located in the selected carrier's Reference > Company Info.
  [Note: 1) If the patient's Secondary Insurance record is tied to an insurance plan, this data will instead pull from the 'Phone' field located in the selected carrier's Reference > Plans > Demographic. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Insurance Phone Extension: This will display the Extension number of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Extension' field located in the selected carrier's Reference > Company Info.
  [Note: 1) If the patient's Secondary Insurance record is tied to an insurance plan, this data will instead pull from the 'Phone' field located in the selected carrier's Reference > Plans > Demographic. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Insurance Plan Contact Person: This will display the Name of the contact person for the insurance plan selected from the 'Plan' popup found in the patient's Secondary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Secondary Insurance Carrier). This data will pull from the 'Contact Person' field located in the selected carrier's Reference > Plans > Demographic.
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patients > Patient > Insurance.]

• Insurance Plan Name: This will display the Name of the insurance plan selected from the 'Plan' popup found in the patient's Secondary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Secondary Insurance Carrier). This data will pull from the 'Plan Name' field found in the Insurance Plan table located in the selected carrier's Reference > Plans.
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patients > Patient > Insurance.]

• Insurance Plan Note: This will display the Notes for the insurance plan selected from the 'Plan' popup found in the patient's Secondary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Secondary Insurance Carrier). This data will pull from the 'Notes' field located in the selected carrier's Reference > Plans > Notes.
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patients > Patient > Insurance.]

• Insurance Plan Type: This will display the Plan Type for the insurance plan selected from the 'Plan Type' popup found in the patient's Secondary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Secondary Insurance Carrier). This data will pull from the 'Plan' popup located in the selected carrier's Reference > Claims.
  [Note: 1) If the patient's Secondary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patients > Patient > Insurance.]

• Insurance Prior Auth Exp Date: This will reflect the date as entered in the 'Expiration Date' field found in the oldest active Prior Authorization record located in Patients > Patient > Incident Menu > Prior Auth. for the patient's most recent incident (dependent upon the patient's Secondary Insurance Carrier being selected from the Prior Auth record's 'Insurance' popup).
  [Note: 1) The oldest active Prior Authorization record is located at the bottom of the list WITH remaining visits located in the Prior Auth tab. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patients > Patient > Insurance.]

• Insurance Prior Auth Start Date: This will reflect the date as entered in the 'Start Date' filed found in the oldest active Prior Authorization record located in Patients > Patient > Incident Menu > Prior Auth. for the patient's most recent incident (dependent upon the patient's Secondary Insurance Carrier being selected from the Prior Auth record's 'Insurance' popup).
  [Note: 1) The oldest active Prior Authorization record is located at the bottom of the list WITH remaining visits located in the Prior Auth tab. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patients > Patient > Insurance.]

• Insurance Prior Auth Total Visits: This will reflect the data as entered in the 'Total Visits' field found in the oldest active Prior Authorization record located in Patients > Patient > Incident Menu > Prior Auth. for the patient's most recent incident (dependent upon the patient's Secondary Insurance Carrier being selected from the Prior Auth record's 'Insurance' popup).
  [Note: 1) The oldest active Prior Authorization record is located at the bottom of the list WITH remaining visits located in the Prior Auth tab. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patients > Patient > Insurance.]

• Insurance Prior Auth Visits Remain: This will reflect the data as entered the 'Remaining Visits' field found in the oldest active Prior Authorization record located in Patients > Patient > Incident Menu > Prior Auth. for the patient's most recent incident (dependent upon the patient's Secondary Insurance Carrier being selected from the Prior Auth record's 'Insurance' popup).
  [Note: 1) The oldest active Prior Authorization record is located at the bottom of the list WITH remaining visits located in the Prior Auth tab. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patients > Patient > Insurance.]

• Insurance Prior Authorization: This will reflect the data as entered in the 'Prior Authorization' field found in the oldest active Prior Authorization record located in Patients > Patient > Incident Menu > Prior Auth. for the patient's most recent incident (dependent upon the patient's Secondary Insurance Carrier being selected from the Prior Auth record's 'Insurance' popup).
  [Note: 1) The oldest active Prior Authorization record is located at the bottom of the list WITH remaining visits located in the Prior Auth tab. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patients > Patient > Insurance.]

• Insurance State: This will display the State of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'State' field located in the selected carrier's Reference > Company Info.
  [Note: 1) If the patient's Secondary Insurance record is tied to an insurance plan, this data will instead pull from the 'State' field located in the selected carrier's Reference > Plans > Demographic. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Insurance Street Address: This will display the Street Address of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Street Address' field located in the selected carrier's Reference > Company Info.
  [Note: 1) If the patient's Secondary Insurance record is tied to an insurance plan, this data will instead pull from the 'Street Address' field located in the selected carrier's Reference > Plans > Demographic. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Insurance Suite: This will display the Suite Number of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Suite' field located in the selected carrier's Reference > Company Info.
  [Note: 1) If the patient's Secondary Insurance record is tied to an insurance plan, this data will instead pull from the 'suite' field located in the selected carrier's Reference > Plans > Demographic. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Insurance Zip Code: This will display the Zip Code of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Zip Code' field located in the selected carrier's Reference > Company Info.
  [Note: 1) If the patient's Secondary Insurance record is tied to an insurance plan, this data will instead pull from the 'Zip Code' field located in the selected carrier's Reference > Plans > Demographic. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Item Description: [Nonfunctional]

• Patient Subscriber Number: This will reflect the data as entered in the 'Subscriber #' field found in the patient's Secondary Insurance Carrier record located in Patients > Patient > Insurance.
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Person Subscriber Number: This will display the Subscriber Number of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Subscriber #' field found in the selected carrier's record located in Patients > Primary or Secondary (dependent upon patient's Secondary Insurance Carrier).
  [Note: 1) The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Policy Holder City: This will display the City for the policy holder of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'City' field located in Patients > Primary or Secondary (dependent upon the patient's Secondary Insurance Carrier).
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Policy Holder Country: This will display the Country for the policy holder of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Country' field located in Patients > Primary or Secondary (dependent upon the patient's Secondary Insurance Carrier).
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Policy Holder First Name: This will display the First Name for the policy holder of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'First Name' field located in Patients > Primary or Secondary (dependent upon the patient's Secondary Insurance Carrier).
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Policy Holder Home Phone: This will display the Home Phone Number for the policy holder of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from a 'Phone' field located in Patients > Primary or Secondary (dependent upon the patient's Secondary Insurance Carrier).
  [Note: 1) The 'Phone' field's adjoining 'Type' popup MUST be set to "Home Phone". 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Policy Holder Last Name: This will display the Last Name for the policy holder of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Last Name' field located in Patients > Primary or Secondary (dependent upon the patient's Secondary Insurance Carrier).
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Policy Holder Middle Name: This will display the Middle Name for the policy holder of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Middle Name' field located in Patients > Primary or Secondary (dependent upon the patient's Secondary Insurance Carrier).
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Policy Holder Mobile Phone: This will display the Mobile Phone Number for the policy holder of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from a 'Phone' field located in Patients > Primary or Secondary (dependent upon the patient's Secondary Insurance Carrier).
  [Note: 1) The 'Phone' field's adjoining 'Type' popup MUST be set to "Mobile Phone". 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Policy Holder Other Phone: This will display the Other Phone Number for the policy holder of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from a 'Phone' field located in Patients > Primary or Secondary (dependent upon the patient's Secondary Insurance Carrier).
  [Note: 1) The 'Phone' field's adjoining 'Type' popup MUST be set to "Other Phone". 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Policy Holder Prefix: This will display the Prefix for the policy holder of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Prefix' field located in Patients > Primary or Secondary (dependent upon the patient's Secondary Insurance Carrier).
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Policy Holder SSN: This will display the Social Security Number for the policy holder of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Social Security' field located in Patients > Primary or Secondary (dependent upon the patient's Secondary Insurance Carrier).
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Policy Holder SSN Last 4: This will display the last four digits of the Social Security Number for the policy holder of the Secondary Insurance Carrier carrier located in Patients > Patient > Insurance. This data will pull from the 'Social Security' field located in Patients > Primary or Secondary (dependent upon the patient's Secondary Insurance Carrier).
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Policy Holder State: This will display the State for the policy holder of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Prefix' field located in Patients > Primary or Secondary (dependent upon the patient's Secondary Insurance Carrier).
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Policy Holder Street Address: This will display the Street Address for the policy holder of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Street Address' field located in Patients > Primary or Secondary (dependent upon the patient's Secondary Insurance Carrier).
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Policy Holder Suffix: This will display the Suffix for the policy holder of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Suffix' field located in Patients > Primary or Secondary (dependent upon the patient's Secondary Insurance Carrier).
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Policy Holder Suite: This will display the Suite Number for the policy holder of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Suite' field located in Patients > Primary or Secondary (dependent upon the patient's Secondary Insurance Carrier).
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Policy Holder Work Phone: This will display the Work Phone Number for the policy holder of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from a 'Phone' field located in Patients > Primary or Secondary (dependent upon the patient's Secondary Insurance Carrier).
  [Note: 1) The 'Phone' field's adjoining 'Type' popup MUST be set to "Work Phone". 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Policy Holder Zip Code: This will display the Zip Code for the policy holder of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Zip Code' field located in Patients > Primary or Secondary (dependent upon the patient's Secondary Insurance Carrier).
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Policy HolderDate of Birth: This will display the Date of Birth for the policy holder of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Birth Date' field located in Patients > Primary or Secondary (dependent upon the patient's Secondary Insurance Carrier).
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Policy Number: This will display the Policy Number of the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Subscriber #' field found in the selected carrier's record located in Patients > Primary or Secondary (dependent upon patient's Secondary Insurance Carrier).
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Remaining Coverage: This will reflect the data as displayed/entered in the 'Remaining Coverage' field found in the patient's Secondary Insurance Carrier record located in Patients > Patient > Insurance.
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Remaining Deductible: This will reflect the data as displayed/entered in the 'Remaining Coverage' field found in the patient's Secondary Insurance Carrier record located in Patients > Patient > Insurance.
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Renewal Date: This will display the Renewal Date for the patient's Secondary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Renewal Date' field for the Secondary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon the patient's Secondary Insurance Carrier).
  [Note: 1) The year will always display as "2008" or "08" due to not being able to enter a year in the 'Renewal Date' field. To avoid this please contact a paper forms specialist. 2) The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in the patient's Insurance tab.]

• Start Date: This will reflect the date as entered in the 'Start Date' field located in the patient's Secondary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Secondary Insurance Carrier).
  [Note: The patient's Secondary Insurance Carrier is determined by the second Insurance record listed in Patient > Patient > Insurance.]

Secondary Procedure Types
Number of items to display and row offset determined by Form Rules.
[Note: Default Form Rules: Max Items - 1; Row Offset - 0.00]

• Procedure Apply Deductible: This is a "True/False" pull field that will display an 'X' respective to having selected the 'Applies to Deductible' checkbox for any procedure type as listed in the Procedure Type table located in the patient's Secondary Insurance Carrier's Reference > Plans > Coverage.
  [Note: 1) Procedure Types MUST be added to References > Procedure Types. 2) The patient's Secondary Insurance Carrier's is determined by the second Insurance record listed in the Insurance table located in Patients > Patient > Insurance. 3) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the checkbox is selected. If formatted for "False", an 'X' will display when the checkbox is deselected. ]

• Procedure Coverage Percent: This will reflect the data as entered in any '% Insurance Pays' field as listed in the Procedure Type table located in the patient's Secondary Insurance Carrier's Reference > Plans > Coverage.
  [Note: 1) Procedure Types MUST be added to References > Procedure Types. 2) The patient's Secondary Insurance Carrier's is determined by the second Insurance record listed in Patients > Patient > Insurance.]

• Procedure Type: This will display the Name of any procedure type as listed under the 'Procedure Type' column of the Procedure Type table located in the patient's Secondary Insurance Carrier's Reference > Plans > Coverage. This data will pull from the 'Description' field located in the selected procedure type's Reference.
  [Note: 1) Procedure Types MUST be added to References > Procedure Types. 2) The patient's Secondary Insurance Carrier's is determined by the second Insurance record listed in Patients > Patient > Insurance.]

Secondary Referral

• BCBS: This will display the BCBS Number of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'BCBS' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Blue Cross: This will display the Blue Cross Number of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Blue Cross' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Cell Phone Number: This will display the Cell Phone Number for the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from a 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
  [Note: 1) The 'Phone Number' field's adjoining "phone type" popup MUST be set to "Cell". 2) The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Central Cert: This will display the Central Cert Number of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Central Cert.' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Champus: This will display the Champus Number of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Blue Cross' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• City: This will display the City of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'City' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Commercial: This will display the Commercial Number of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Commercial' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Date: This will reflect the date as entered in the 'Referral Date' field of the patient's Secondary Referral located in Patients > Patient > Referrals.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Department: This will display Department for the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Dept.' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Disability: This will display the Disability Number of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Disability' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Email: This will display the Email Address for the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'email' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Expiration Date: This will display the Expiration Date for the patient's Secondary Referral located in Patients > Patient > Referrals. This date is calculated by beginning with the Referral Date then adding the month range as selected from the 'Months' popup located in the selected Referrer record.
  [Note: 1) To activate the 'Expiration Date'/'Months' field/popup the 'Use Referrals Expiration Date' checkbox MUST be selected from References > Localizaion (not available in DDS). 2) When using this field in DDS or selecting 'Indefinite' from the 'Months' popup for other flavors, MacPractice should display the date as 12 months from the Referral date. However it displays the date as the previous month of the same year. 3) The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Expiration Months: This will reflect the data as selected from the 'Months' popup found in the patient's Secondary Referral located in Patients > Patient > Referrals.
  [Note: 1) The 'Use Referrals Expiration Date' checkbox MUST be selected from References > Localization. 2) The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Family/Friend: [Nonfunctional]

• Fax Number: This will display the Fax Number for the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from a 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
  [Note: 1) The 'Phone Number' field's adjoining "phone type" popup MUST be set to "Fax". 2) The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Federal Employee: This will display the Federal Employee Number of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Federal Employee' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• HMO: This will display the Number of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'HMO' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Home Phone Number: This will display the Home Phone Number for the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from a 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
  [Note: 1) The 'Phone Number' field's adjoining "type" popup MUST be set to "Home". 2) The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Managed Care: This will display the Managed Care Number of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Managed' field located in the selected referral's Reference > Provider IDs.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Medicaid: This will display the Medicaid Number of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Medicaid' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Medicare: This will display the Medicare Number of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Medicare Part B' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Name, First: This will display the First Name of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'First' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Name, Last: This will display the Last Name of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Last' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Name, Middle: This will display the Middle Name of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Middle' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Name, Nickname: This will display the Nickname of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Nickname (AKA)' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Name, Professional Title: This will display the Professional Title of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Prefix' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Name, Suffix: This will display the Suffix of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Suffix' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• National Provider ID: This will display the NPI Number for the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'National Provider ID (NPI)' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's secondary referral is determined by the second Referral record listed in the Referrals tab.]

•  Office: This will display the Company Name of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Office/Company' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's secondary referral is determined by the second Referral record listed in the Referrals tab.]

• Other: This will display the Other Non-Federal Number of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Other Non-Federal' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Other Federal: This will display the Other Federal Number of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Other Federal' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• PPO: This will display the PPO Number of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'PPO' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Position Title: This will display the Title/Position of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Title/Position' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Primary Insurance ID: This will display the Insurance ID Number of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Commercial' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• SSN/TID: This will display the Social Security Number/Tax ID for the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'SSN/TID' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Secondary Insurance ID: This will display the Secondary Insurance ID Number of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Commercial' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Self Admin: This will display the Self Admin Number of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Self Admin' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Self Pay: This will display the Self Pay Number of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Self Pay' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• State: This will display the State of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'State' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• State License: This will display the State License Number of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'State License' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Street Address: This will display the Street Address of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Street Address' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Suite: This will display the Suite Number of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Suite' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Taxonomy Code: This will display the Taxonomy/Specialty Code of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Taxonomy (Specialty)' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Tertiary Insurance ID: [Nonfunctional]

• Title V: This will display the Title V Number of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Title V' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Vets Admin: This will display the Vets Admin Number of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Vets Admin.' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Work Phone Number: This will display the Work Phone Number for the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from a 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
  [Note: 1) The 'Phone Number' field's adjoining "phone type" popup MUST be set to "Work". 2) The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Workers Compensation: This will display the Workers Compensation Number of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Workers Compensation.' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

• Zip Code: This will display the Zip Code of the patient's Secondary Referral located in Patients > Patient > Referrals. This data will pull from the 'Zip Code' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Secondary Referral is determined by the second Referral record listed in the Referrals tab.]

Tertiary Insurance  

• Copay: This will reflect the data as entered in the 'Copay' field found in the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance.
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Dependent Code: This will reflect the data as entered in the 'Dependent Code' field found in the patient's Tertiary Insurance Carrier record located in Patients > Patient > Insurance.
  [Note: 1) The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Division/Section Number: This will display the Division/Section Number of the patient's Tertiary insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Division/Section' field of the selected Carrier's record found in the Insurance table located in Patients > Primary or Secondary (dependent upon patient's Tertiary Insurance Carrier).
  [Note: 1) The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Employer Address: This will display the Street Address of the employer selected from the 'Employer' popup found in the patient's Tertiary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Tertiary Insurance Carrier). This data will pull from the 'Street Address' field located in the selected employer's Reference.
  [Note: 1) An Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance.]

• Employer City: This will display the City of the employer selected from the 'Employer' popup found in the patient's Tertiary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Tertiary Insurance Carrier). This data will pull from the 'City' field located in the selected employer's Reference.
  [Note: 1) An Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance.]

• Employer Extension: This will display the Phone Extension of the employer selected from the 'Employer' popup found in the patient's Tertiary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Tertiary Insurance Carrier). This data will pull from the 'Extension' field located in the selected employer's Reference.
  [Note: 1) An Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance.]

• Employer Group Number: This will display the Group Number of the employer selected from the 'Employer' popup found in the patient's Tertiary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Tertiary Insurance Carrier). This data will pull from the 'Group #' field located in the selected employer's Reference.
  [Note: 1) An Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance.]

• Employer Name: This will display the Name of the employer selected from the 'Employer' popup found in the patient's Tertiary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Tertiary Insurance Carrier). This data will pull from the 'Employer Name' field located in the selected employer's Reference.
  [Note: 1) An Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance.]

• Employer Phone: This will display the Phone Number of the employer selected from the 'Employer' popup found in the patient's Tertiary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Tertiary Insurance Carrier). This data will pull from the 'Phone' field located in the selected employer's Reference.
  [Note: 1) An Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance.]

• Employer State: This will display the State of the employer selected from the 'Employer' popup found in the patient's Tertiary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Tertiary Insurance Carrier). This data will pull from the 'State' field located in the selected employer's Reference.
  [Note: 1) An Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance.]

• Employer Suite: This will display the Suite Number of the employer selected from the 'Employer' popup found in the patient's Tertiary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Tertiary Insurance Carrier). This data will pull from the 'Suite' field located in the selected employer's Reference.
  [Note: 1) An Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance.]

• Employer Zip Code: This will display the Zip Code of the employer selected from the 'Employer' popup found in the patient's Tertiary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Tertiary Insurance Carrier). This data will pull from the 'Zip Code' field located in the selected employer's Reference.
  [Note: 1) An Employer record MUST be added Employers table located in Patients > Primary or Secondary. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance.]

• End Date: This will display the End Date of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'End Date' field found in the Insurance table located in Patients > Primary or Secondary (dependent upon patient's Tertiary Insurance Carrier).
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Group Number: This will display the Group Number for the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Group #' field found in the selected Carrier's record located in Patients > Primary or Secondary (dependent upon patient's Tertiary Insurance Carrier).
  [Note: 1) When the Tertiary Insurance record has an employer selected for the 'Employer' popup, this data will instead pull from the 'Group #' field located in the selected employer's record. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance.]

• Insurance Carrier: This will display the Name of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Insurance Company' field located in the selected carrier's Reference > Company Info.
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Insurance City: This will display the City of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'City' field located in the selected carrier's Reference > Company Info.
  [Note: 1) If the patient's Tertiary Insurance record is tied to an insurance plan, this data will instead pull from the 'City' field located in the selected carrier's Reference > Plans > Demographic. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Insurance Contact Person: This will display the Name of the contact person for the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Contact Person' field located in the selected carrier's Reference > Company Info.
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Insurance Fax Number: This will display the Fax Number of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Contact Person' field located in the selected carrier's Reference > Company Info.
  [Note: 1) If the patient's Tertiary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Demographic. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Insurance Has Prior Authorization: This is a "True/False" pull field that will display an 'X' respective to having selected the patient's Tertiary Insurance Carrier from the 'Insurance' popup for any Prior Authorization record added to the Prior Authorization table located in Patients > Ledger > Incident Menu > Prior Auth.
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance. 2) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when a prior auth. is selected. If formatted for "False", an 'X' will display when a prior auth. is not selected.]

• Insurance Is ChampVA: This is a "True/False" pull field that will display an 'X' respective to having selected 'Veterans Administration Plan' from the 'Plan' popup located in the patient's Tertiary Insurance Carrier's Reference > Claims.
  [Note: 1) If the patient's Tertiary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance. 3) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected.]

• Insurance is Champus: This is a "True/False" pull field that will display an 'X' respective to having selected 'Champus' from the 'Plan' popup located in the patient's Tertiary insurance Carrier's Reference > Claims.
  [Note: 1) If the Tertiary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance. 3) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected]

• Insurance is FECA: This is a "True/False" pull field that will display an 'X' respective to having selected 'Other Federal Program' from the 'Plan' popup located in the patient's Tertiary Insurance Carrier's Reference > Claims.
  [Note: 1) If the patient's Tertiary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance. 3) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected

• Insurance is Group Health Plan: This is a "True/False" pull field that will display an 'X' respective to having selected 'Preferred Provider Organization (PPO)/Exclusive Provider Organization (EPO)/Health Maintenance Organization (HMO)' from the 'Plan' popup located in the patient's Tertiary Insurance Carrier's Reference > Claims.
  [Note: 1) If the patient's Tertiary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance. 3) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected]

• Insurance is Medicaid: This is a "True/False" pull field that will display an 'X' respective to having selected 'Medicaid' from the 'Plan' popup located in the patient's Tertiary Insurance Carrier's Reference > Claims.
  [Note: 1) If the patient's Tertiary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance. 3) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected]

• Insurance is Medicare: This is a "True/False" pull field that will display an 'X' respective to having selected 'Medicare Part B' from the 'Plan' popup located in the patient's Tertiary Insurance Carrier's Reference > Claims.
  [Note: 1) If the patient's Tertiary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance. 3) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected]

• Insurance is Other Plan Type: This is a "True/False" pull field that will display an 'X' respective to having selected 'Self-pay/Central Certification/Other Non-Federal Programs/Point of Service(POS)/Indemnity Insurance/HMO Medicare Risk/Automobile Medical/Blue Cross / Blue Shield/Commercial Insurance Co./Disability/Liability/Liability Medical/Title V/Workers Compensation Health Claim/Mutually Defined Unknown' from the 'Plan' popup located in the patient's Tertiary Insurance Carrier's Reference > Claims.
  [Note: 1) If the patient's Tertiary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance. 3) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the item is selected. If formatted for "False", an 'X' will display when the item is not selected]

• Insurance Phone: This will display the Phone Number of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Phone' field located in the selected carrier's Reference > Company Info.
  [Note: 1) If the patient's Tertiary Insurance record is tied to an insurance plan, this data will instead pull from the 'Phone' field located in the selected carrier's Reference > Plans > Demographic. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Insurance Phone Extension: This will display the Extension number of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Extension' field located in the selected carrier's Reference > Company Info.
  [Note: 1) If the patient's Tertiary Insurance record is tied to an insurance plan, this data will instead pull from the 'Phone' field located in the selected carrier's Reference > Plans > Demographic. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Insurance Plan Contact Person: This will display the Name of the contact person for the insurance plan selected from the 'Plan' popup found in the patient's Tertiary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Tertiary Insurance Carrier). This data will pull from the 'Contact Person' field located in the selected carrier's Reference > Plans > Demographic.
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance.]

• Insurance Plan Name: This will display the Name of the insurance plan selected from the 'Plan' popup found in the patient's Tertiary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Tertiary Insurance Carrier). This data will pull from the 'Plan Name' field found in the Insurance Plan table located in the selected carrier's Reference > Plans.
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance.]

• Insurance Plan Note: This will display the Notes for the insurance plan selected from the 'Plan' popup found in the patient's Tertiary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Tertiary Insurance Carrier). This data will pull from the 'Notes' field located in the selected carrier's Reference > Plans > Notes.
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance.]

• Insurance Plan Type: This will display the Plan Type for the insurance plan selected from the 'Plan Type' popup found in the patient's Tertiary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Tertiary Insurance Carrier). This data will pull from the 'Plan' popup located in the selected carrier's Reference > Claims.
  [Note: 1) If the patient's Tertiary Insurance record is tied to an insurance plan, this data will instead pull from the 'Plan Type' popup located in the selected carrier's Reference > Plans > Coverage. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance.]

• Insurance Prior Auth Exp Date: This will reflect the date as entered in the 'Expiration Date' field found in the oldest active Prior Authorization record located in Patients > Patient > Incident Menu > Prior Auth. for the patient's most recent incident (dependent upon the patient's Tertiary Insurance Carrier being selected from the Prior Auth record's 'Insurance' popup).
  [Note: 1) The oldest active Prior Authorization record is located at the bottom of the list WITH remaining visits located in the Prior Auth tab. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance.]

• Insurance Prior Auth Start Date: This will reflect the date as entered in the 'Start Date' filed found in the oldest active Prior Authorization record located in Patients > Patient > Incident Menu > Prior Auth. for the patient's most recent incident (dependent upon the patient's Tertiary Insurance Carrier being selected from the Prior Auth record's 'Insurance' popup).
  [Note: 1) The oldest active Prior Authorization record is located at the bottom of the list WITH remaining visits located in the Prior Auth tab. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance.]

• Insurance Prior Auth Total Visits: This will reflect the data as entered in the 'Total Visits' field found in the oldest active Prior Authorization record located in Patients > Patient > Incident Menu > Prior Auth. for the patient's most recent incident (dependent upon the patient's Tertiary Insurance Carrier being selected from the Prior Auth record's 'Insurance' popup).
  [Note: 1) The oldest active Prior Authorization record is located at the bottom of the list WITH remaining visits located in the Prior Auth tab. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance.]

• Insurance Prior Auth Visits Remain: This will reflect the data as entered the 'Remaining Visits' field found in the oldest active Prior Authorization record located in Patients > Patient > Incident Menu > Prior Auth. for the patient's most recent incident (dependent upon the patient's Tertiary Insurance Carrier being selected from the Prior Auth record's 'Insurance' popup).
  [Note: 1) The oldest active Prior Authorization record is located at the bottom of the list WITH remaining visits located in the Prior Auth tab. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance.]

• Insurance Prior Authorization: This will reflect the data as entered in the 'Prior Authorization' field found in the oldest active Prior Authorization record located in Patients > Patient > Incident Menu > Prior Auth. for the patient's most recent incident (dependent upon the patient's Tertiary Insurance Carrier being selected from the Prior Auth record's 'Insurance' popup).
  [Note: 1) The oldest active Prior Authorization record is located at the bottom of the list WITH remaining visits located in the Prior Auth tab. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance.]

• Insurance State: This will display the State of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'State' field located in the selected carrier's Reference > Company Info.
  [Note: 1) If the patient's Tertiary Insurance record is tied to an insurance plan, this data will instead pull from the 'State' field located in the selected carrier's Reference > Plans > Demographic. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Insurance Street Address: This will display the Street Address of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Street Address' field located in the selected carrier's Reference > Company Info.
  [Note: 1) If the patient's Tertiary Insurance record is tied to an insurance plan, this data will instead pull from the 'Street Address' field located in the selected carrier's Reference > Plans > Demographic. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Insurance Suite: This will display the Suite Number of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Suite' field located in the selected carrier's Reference > Company Info.
  [Note: 1) If the patient's Tertiary Insurance record is tied to an insurance plan, this data will instead pull from the 'suite' field located in the selected carrier's Reference > Plans > Demographic. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Insurance Zip Code: This will display the Zip Code of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Zip Code' field located in the selected carrier's Reference > Company Info.
  [Note: 1) If the patient's Tertiary Insurance record is tied to an insurance plan, this data will instead pull from the 'Zip Code' field located in the selected carrier's Reference > Plans > Demographic. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Item Description: [Nonfunctional]

• Patient Subscriber Number: This will reflect the data as entered in the 'Subscriber #' field found in the patient's Tertiary Insurance Carrier record located in Patients > Patient > Insurance.
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Person Subscriber Number: This will display the Subscriber Number of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Subscriber #' field found in the selected carrier's record located in Patients > Primary or Secondary (dependent upon patient's Tertiary Insurance Carrier).
  [Note: 1) The 'Use Canadian Claim Fields' checkbox MUST be selected from Preferences > Localization. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Policy Holder City: This will display the City for the policy holder of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'City' field located in Patients > Primary or Secondary (dependent upon the patient's Tertiary Insurance Carrier).
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Policy Holder Country: This will display the Country for the policy holder of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Country' field located in Patients > Primary or Secondary (dependent upon the patient's Tertiary Insurance Carrier).
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Policy Holder Date of Birth: This will display the Date of Birth for the policy holder of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Birth Date' field located in Patients > Primary or Secondary (dependent upon the patient's Tertiary Insurance Carrier).
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Policy Holder First Name: This will display the First Name for the policy holder of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'First Name' field located in Patients > Primary or Secondary (dependent upon the patient's Tertiary Insurance Carrier).
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Policy Holder Home Phone: This will display the Home Phone Number for the policy holder of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from a 'Phone' field located in Patients > Primary or Secondary (dependent upon the patient's Tertiary Insurance Carrier).
  [Note: 1) The 'Phone' field's adjoining 'Type' popup MUST be set to "Home Phone". 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Policy Holder Last Name: This will display the Last Name for the policy holder of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Last Name' field located in Patients > Primary or Secondary (dependent upon the patient's Tertiary Insurance Carrier).
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Policy Holder Middle Name: This will display the Middle Name for the policy holder of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Middle Name' field located in Patients > Primary or Secondary (dependent upon the patient's Tertiary Insurance Carrier).
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Policy Holder Mobile Phone: This will display the Mobile Phone Number for the policy holder of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from a 'Phone' field located in Patients > Primary or Secondary (dependent upon the patient's Tertiary Insurance Carrier).
  [Note: 1) The 'Phone' field's adjoining 'Type' popup MUST be set to "Mobile Phone". 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Policy Holder Other Phone: This will display the Other Phone Number for the policy holder of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from a 'Phone' field located in Patients > Primary or Secondary (dependent upon the patient's Tertiary Insurance Carrier).
  [Note: 1) The 'Phone' field's adjoining 'Type' popup MUST be set to "Other Phone". 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Policy Holder Prefix: This will display the Prefix for the policy holder of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Prefix' field located in Patients > Primary or Secondary (dependent upon the patient's Tertiary Insurance Carrier).
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Policy Holder SSN: This will display the Social Security Number for the policy holder of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Social Security' field located in Patients > Primary or Secondary (dependent upon the patient's Tertiary Insurance Carrier).
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Policy Holder SSN Last 4: This will display the last four digits of the Social Security Number for the policy holder of the Tertiary Insurance Carrier carrier located in Patients > Patient > Insurance. This data will pull from the 'Social Security' field located in Patients > Primary or Secondary (dependent upon the patient's Tertiary Insurance Carrier).
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Policy Holder State: This will display the State for the policy holder of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Prefix' field located in Patients > Primary or Secondary (dependent upon the patient's Tertiary Insurance Carrier).
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Policy Holder Street Address: This will display the Street Address for the policy holder of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Street Address' field located in Patients > Primary or Secondary (dependent upon the patient's Tertiary Insurance Carrier).
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Policy Holder Suffix: This will display the Suffix for the policy holder of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Suffix' field located in Patients > Primary or Secondary (dependent upon the patient's Tertiary Insurance Carrier).
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Policy Holder Suite: This will display the Suite Number for the policy holder of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Suite' field located in Patients > Primary or Secondary (dependent upon the patient's Tertiary Insurance Carrier).
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Policy Holder Work Phone: This will display the Work Phone Number for the policy holder of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from a 'Phone' field located in Patients > Primary or Secondary (dependent upon the patient's Tertiary Insurance Carrier).
  [Note: 1) The 'Phone' field's adjoining 'Type' popup MUST be set to "Work Phone". 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Policy Holder Zip Code: This will display the Zip Code for the policy holder of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Zip Code' field located in Patients > Primary or Secondary (dependent upon the patient's Tertiary Insurance Carrier).
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Policy Number: This will display the Policy Number of the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Subscriber #' field found in the selected carrier's record located in Patients > Primary or Secondary (dependent upon patient's Tertiary Insurance Carrier).
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Remaining Coverage: This will reflect the data as displayed/entered in the 'Remaining Coverage' field found in the patient's Tertiary Insurance Carrier record located in Patients > Patient > Insurance.
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Remaining Deductible: This will reflect the data as displayed/entered in the 'Remaining Coverage' field found in the patient's Tertiary Insurance Carrier record located in Patients > Patient > Insurance.
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Renewal Date: This will display the Renewal Date for the patient's Tertiary Insurance Carrier located in Patients > Patient > Insurance. This data will pull from the 'Renewal Date' field for the Tertiary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon the patient's Tertiary Insurance Carrier).
  [Note: 1) The year will always display as "2008" or "08" due to not being able to enter a year in the 'Renewal Date' field. To avoid this please contact a paper forms specialist. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in the patient's Insurance tab.]

• Start Date: This will reflect the date as entered in the 'Start Date' field located in the patient's Tertiary Insurance Carrier record located in Patients > Primary or Secondary (dependent upon patient's Tertiary Insurance Carrier).
  [Note: The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patient > Patient > Insurance.]

Tertiary Procedure Types
Number of items to display and row offset determined by Form Rules.
[Note: Default Form Rules: Max Items - 1; Row Offset - 0.00]

• Procedure Apply Deductible: This is a "True/False" pull field that will display an 'X' respective to having selected the 'Applies to Deductible' checkbox for any procedure type as listed in the Procedure Type table located in the patient's Tertiary Insurance Carrier's Reference > Plans > Coverage.
  [Note: 1) Procedure Types MUST be added to References > Procedure Types. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance. 3) Functionality is dependent upon pull field formatting. If formatted for "True", an 'X' will display when the checkbox is selected. If formatted for "False", an 'X' will display when the checkbox is deselected.]

• Procedure Coverage Percent: This will reflect the data as entered in any '% Insurance Pays' field as listed in the Procedure Type table located in the patient's Tertiary Insurance Carrier's Reference > Plans > Coverage.
  [Note: 1) Procedure Types MUST be added to References > Procedure Types. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance.]

• Procedure Type: This will display the Name of any procedure type as listed under the 'Procedure Type' column of the Procedure Type table located in the patient's Tertiary Insurance Carrier's Reference > Plans > Coverage. This data will pull from the 'Description' field located in the selected procedure type's Reference.
  [Note: 1) Procedure Types MUST be added to References > Procedure Types. 2) The patient's Tertiary Insurance Carrier is determined by the third Insurance record listed in Patients > Patient > Insurance.]

Tertiary Referral

• BCBS: This will display the BCBS Number of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'BCBS' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Blue Cross: This will display the Blue Cross Number of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Blue Cross' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Cell Phone Number: This will display the Cell Phone Number for the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from a 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
  [Note: 1) The 'Phone Number' field's adjoining "phone type" popup MUST be set to "Cell". 2) The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Central Cert: This will display the Central Cert Number of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Central Cert.' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Champus: This will display the Champus Number of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Blue Cross' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• City: This will display the City of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'City' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Commercial: This will display the Commercial Number of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Commercial' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Date: This will reflect the date as entered in the 'Referral Date' field of the patient's Tertiary Referral located in Patients > Patient > Referrals.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Department: This will display Department for the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Dept.' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Disability: This will display the Disability Number of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Disability' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Email: This will display the Email Address for the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'email' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Expiration Date: This will display the Expiration Date for the patient's Tertiary Referral located in Patients > Patient > Referrals. This date is calculated by beginning with the Referral Date then adding the month range as selected from the 'Months' popup located in the selected Referrer record.
  [Note: 1) To activate the 'Expiration Date'/'Months' field/popup the 'Use Referrals Expiration Date' checkbox MUST be selected from References > Localizaion (not available in DDS). 2) When using this field in DDS or selecting 'Indefinite' from the 'Months' popup for other flavors, MacPractice should display the date as 12 months from the Referral date. However it displays the date as the previous month of the same year. 3) The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Expiration Months: This will reflect the data as selected from the 'Months' popup found in the patient's Tertiary Referral record located in Patients > Patient > Referrals.
  [Note: 1) The 'Use Referrals Expiration Date' checkbox MUST be selected from References > Localization. 2) The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Family/Friend: [Nonfunctional]

• Fax Number: This will display the Fax Number for the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from a 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
  [Note: 1) The 'Phone Number' field's adjoining "phone type" popup MUST be set to "Fax". 2) The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Federal Employee: This will display the Federal Employee Number of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Federal Employee' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• HMO: This will display the Number of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'HMO' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Home Phone Number: This will display the Home Phone Number for the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from a 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
  [Note: 1) The 'Phone Number' field's adjoining "phone type" popup MUST be set to "Home". 2) The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Managed Care: This will display the Managed Care Number of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Managed' field located in the selected referral's Reference > Provider IDs.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Medicaid: This will display the Medicaid Number of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Medicaid' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Medicare: This will display the Medicare Number of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Medicare Part B' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Name, First: This will display the First Name of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'First' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Name, Last: This will display the Last Name of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Last' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Name, Middle: This will display the Middle Name of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Middle' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Name, Nickname: This will display the Nickname of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Nickname (AKA)' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Name, Professional Title: This will display the Professional Title of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Prefix' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Name, Suffix: This will display the Suffix of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Suffix' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• National Provider ID: This will display the NPI Number for the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'National Provider ID (NPI)' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

•  Office: This will display the Company Name of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Office/Company' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Other: This will display the Other Non-Federal Number of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Other Non-Federal' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Other Federal: This will display the Other Federal Number of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Other Federal' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• PPO: This will display the PPO Number of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'PPO' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Position Title: This will display the Title/Position of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Title/Position' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Primary Insurance ID: This will display the Insurance ID Number of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Commercial' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• SSN/TID: This will display the Social Security Number/Tax ID for the patient's Tertiary Referral in Patients > Patient > Referrals. This data will pull from the 'SSN/TID' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Secondary Insurance ID: This will display the Secondary Insurance ID Number of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Commercial' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Self Admin: This will display the Self Admin Number of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Self Admin' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Self Pay: This will display the Self Pay Number of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Self Pay' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• State: This will display the State of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'State' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• State License: This will display the State License Number of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'State License' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Street Address: This will display the Street Address of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Street Address' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Suite: This will display the Suite Number of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Suite' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Taxonomy Code: This will display the Taxonomy/Specialty Code of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Taxonomy (Specialty)' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Tertiary Insurance ID: [Nonfunctional]

• Title V: This will display the Title V Number of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Title V' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Vets Admin: This will display the Vets Admin Number of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Vets Admin.' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Work Phone Number: This will display the Work Phone Number for the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from a 'Phone Numbers' field located in the selected referrer's Reference > Referrer Info.
  [Note: 1) The 'Phone Number' field's adjoining "phone type" popup MUST be set to "Work". 2) The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Workers Compensation: This will display the Workers Compensation Number of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Workers Compensation.' field located in the selected referrer's Reference > Provider IDs.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

• Zip Code: This will display the Zip Code of the patient's Tertiary Referral located in Patients > Patient > Referrals. This data will pull from the 'Zip Code' field located in the selected referrer's Reference > Referrer Info.
  [Note: The patient's Tertiary Referral is determined by the third Referral record listed in the Referrals tab.]

Treatments
Number of items to display and row offset determined by Form Rules.
If the Form Rules establish a 'Max Number' of items that is fewer than the number of procedures added to the treatment plan, the form will print additional pages until all procedures have been printed.
[Note: Default Form Rules: Max Items - 6; Row Offset - 20.00]

• Allowed Amount: This will display the Allowed Amount for any treatment added to the patient's treatment plan. This data will pull from the 'Allowed' field found in the Procedures table (located in the patient's primary insurance Reference > Plans > Procedures) for the selected treatment.
  [Note: The order in which the treatments will display is determined by the 'Sort Treatment Plans By' popup located in Preferences > Forms > Settings. (Code or Tooth)]

• Treatment Charge Amount: This will display the Charge Amount for any treatment added to the patient's treatment plan. This data will pull from the selected procedure's 'Unit Fee' field located in its Fee Schedule record, but can be modified from the 'Unit Fee' field located in the Treatment Window.
  [Note: The order in which the treatments will display is determined by the 'Sort Treatment Plans By' popup located in Preferences > Forms > Settings. (Code or Tooth)]

• Treatment Clinical Notes: [Nonfunctional]

• Treatment Code: This will display the Treatment Code as found under the 'Code' column for any procedure added to the Treatment Plan located in Patients > Ledger > Treatment Plan. This data will pull from the 'Code' field located in the Fee Schedule for the selected procedure at the time the treatment was added to the plan.
  [Note: The order in which the treatments will display is determined by the 'Sort Treatment Plans By' popup located in Preferences > Forms > Settings. (Code or Tooth)]

• Treatment Description: This will display the Treatment Description as found under the 'Description' column for any procedure added to the Treatment Plan located in Patients > Ledger > Treatment Plan. This data will pull from the 'Short Description' field located in the Fee Schedule for the selected procedure at the time the treatment was added to the plan.
  [Note: The order in which the treatments will display is determined by the 'Sort Treatment Plans By' popup located in Preferences > Forms > Settings. (Code or Tooth)]

• Treatment Diagnosis 1: This will display the Diagnosis Code as found under the 'Diagnosis 1' column for any procedure added to the Treatment Plan located in Patients > Ledger > Treatment Plan. This data will pull from the first (checked) diagnosis code located in the procedure's Treatment Window > Diagnosis.
  [Note: The order in which the treatments will display is determined by the 'Sort Treatment Plans By' popup located in Preferences > Forms > Settings. (Code or Tooth)]

• Treatment Diagnosis 1 Description: This will display the Diagnosis Description as determined by the first (checked) diagnosis added to the Treatment Window for any procedure added to the Treatment Plan located in Patients > Ledger > Treatment Plan.
  [Note: The order in which the treatments will display is determined by the 'Sort Treatment Plans By' popup located in Preferences > Forms > Settings. (Code or Tooth)]

• Treatment Diagnosis 2: This will display the Diagnosis Code as found under the 'Diagnosis 2' column for any procedure added to the Treatment Plan located in Patients > Ledger > Treatment Plan. This data will pull from the second (checked) diagnosis code located in the procedure's Treatment Window > Diagnosis.
  [Note: The order in which the treatments will display is determined by the 'Sort Treatment Plans By' popup located in Preferences > Forms > Settings. (Code or Tooth)]

• Treatment Diagnosis 2 Description: This will display the Diagnosis Description as determined by the second (checked) diagnosis added to the Treatment Window for any procedure added to the Treatment Plan located in Patients > Ledger > Treatment Plan.
  [Note: The order in which the treatments will display is determined by the 'Sort Treatment Plans By' popup located in Preferences > Forms > Settings. (Code or Tooth)]

• Treatment Diagnosis 3: This will display the Diagnosis Code as found under the 'Diagnosis 3' column for any procedure added to the Treatment Plan located in Patients > Ledger > Treatment Plan. This data will pull from the third (checked) diagnosis code located in the procedure's Treatment Window > Diagnosis.
  [Note: The order in which the treatments will display is determined by the 'Sort Treatment Plans By' popup located in Preferences > Forms > Settings. (Code or Tooth)]

• Treatment Diagnosis 3 Description: This will display the Diagnosis Description as determined by the third (checked) diagnosis added to the Treatment Window for any procedure added to the Treatment Plan located in Patients > Ledger > Treatment Plan.
  [Note: The order in which the treatments will display is determined by the 'Sort Treatment Plans By' popup located in Preferences > Forms > Settings. (Code or Tooth)]

• Treatment Diagnosis 4: This will display the Diagnosis Code as found under the 'Diagnosis 4' column for any procedure added to the Treatment Plan located in Patients > Ledger > Treatment Plan. This data will pull from the fourth (checked) diagnosis code located in the procedure's Treatment Window > Diagnosis.
  [Note: The order in which the treatments will display is determined by the 'Sort Treatment Plans By' popup located in Preferences > Forms > Settings. (Code or Tooth)]

• Treatment Diagnosis 4 Description: This will display the Diagnosis Description as determined by the fourth (checked) diagnosis added to the Treatment Window of any procedure added to the Treatment Plan located in Patients > Ledger > Treatment Plan.
  [Note: The order in which the treatments will display is determined by the 'Sort Treatment Plans By' popup located in Preferences > Forms > Settings. (Code or Tooth)]

• Treatment Discount Amount: This will display the amount discounted for any procedure added to the Treatment Plan located in Patients > Ledger > Treatment Plan. This amount will be calculated by the "Percent Discount (%)" for the account (located in Patients > Account) at the time the selected treatment was added to the Treatment Plan.
  [Note: The order in which the treatments will display is determined by the 'Sort Treatment Plans By' popup located in Preferences > Forms > Settings. (Code or Tooth)]

• Treatment Insurance Amount:  This will display the Insurance Portion as found under the 'Pri Ins Portion' column (located in the Procedure table found in the Treatment Window) for any procedure added to the Treatment Plan located in Patients > Ledger > Treatment Plan.
  [Note: 1) The Insurance Portion is determined by the 'Procedure Type' popup located in the Treatment Window of the selected procedure. This portion is calculated by the '% Insurance Pays' field located in the primary insurance Reference > Plans > Coverage for the selected Procedure Type. 2) The order in which the treatments will display is determined by the 'Sort Treatment Plans By' popup located in Preferences > Forms > Settings. (Code or Tooth)]

• Treatment Long Description: This will reflect the data as entered in the 'Long Description' field (located in the Fee Schedule > Long Description) for any procedure added to the Treatment Plan located in Patients > Ledger > Treatment Plan.
  [Note: The order in which the treatments will display is determined by the 'Sort Treatment Plans By' popup located in Preferences > Forms > Settings. (Code or Tooth)]

• Treatment Notes: [Nonfunctional]

• Treatment Patient Amount:  This will display the Patient Portion as found under the 'Pat Portion' column (located in the Procedure table found in the Treatment Window) for any procedure added to the Treatment Plan located in Patients > Ledger > Treatment Plan.
  [Note: 1) The Patient Portion is determined by the 'Procedure Type' popup located in the Treatment Window of the selected procedure. This portion is calculated by the '% Insurance Pays' field located in the primary insurance Reference > Plans > Coverage for the selected Procedure Type. 2) The order in which the treatments will display is determined by the 'Sort Treatment Plans By' popup located in Preferences > Forms > Settings. (Code or Tooth)]

• Treatment Quadrant Code: This will display a numeric code reflective of the data selected from the 'Area of Oral Cavity' popup found in the Treatment Window for any procedure added to the Treatment Plan located in Patients > Ledger > Treatment Plan.
  [Note: DDS only.]

• Treatment Quadrant Description: This will reflect the Quadrant Description as selected from the 'Area of Oral Cavity' popup located in the Treatment Window for any procedure added to the Treatment Plan located in Patients > Ledger > Treatment Plan.
  [Note: 1) DDS only. 2) The order in which the treatments will display is determined by the 'Sort Treatment Plans By' popup located in Preferences > Forms > Settings. (Code or Tooth)]

• Treatment Resources: This will display the Resource Name for any procedure(s) added to the Treatment Plan (located in Patients > Ledger > Treatment Plan) that have been tied to a scheduled appointment. This data will pull from the 'Name' field found in the resource Reference for the appointment scheduled under the selected resource located in the Schedule.
  [Note: The order in which the treatments will display is determined by the 'Sort Treatment Plans By' popup located in Preferences > Forms > Settings. (Code or Tooth)]

• Treatment Status: This will display the Appointment Status for any procedure(s) added to the Treatment Plan table (located in Patients > Ledger > Treatment Plan) that have been tied to a scheduled appointment. This data will pull the 'Status' dropdown found in the selected appointment's Appointment Detail Window located in the Schedule.
  [Note: The order in which the treatments will display is determined by the 'Sort Treatment Plans By' popup located in Preferences > Forms > Settings. (Code or Tooth)]

• Treatment Surface: This will reflect the Treatment Surface as entered in the 'Surface' field (located in the Treatment Window) for any procedure(s) added to the Treatment Plan located in Patients > Ledger > Treatment Plan.
  [Note: The order in which the treatments will display is determined by the 'Sort Treatment Plans By' popup located in Preferences > Forms > Settings. (Code or Tooth)]

• Treatment Today Insurance Amount: This will display the Insurance Portion as found under the 'Insurance Portion' column for all procedure(s) added to the Treatment Plan table (located in Patients > Ledger > Treatment Plan) that have been tied to a scheduled appointment for the current day. 

• Treatment Today Patient Amount: This will display the Patient Portion as found under the 'Patient Portion' column for all procedure(s) added to the Treatment Plan table (located in Patients > Ledger > Treatment Plan) that have been tied to a scheduled appointment for the current day.

• Treatment Tooth: This will reflect the Tooth Number as entered in the 'Tooth' field (located in the Treatment Window) for any procedure(s) added to the Treatment Plan located in Patients > Ledger > Treatment Plan.
  [Note: The order in which the treatments will display is determined by the 'Sort Treatment Plans By' popup located in Preferences > Forms > Settings. (Code or Tooth)]

• Treatment Total Number Today: This will display the total number of all procedure(s) added to the Treatment Plan table (located in Patients > Ledger > Treatment Plan) that have been tied to a scheduled appointment for the current day.

• Treatment Usage Notes: This will reflect the data as entered in the 'Usage Notes' field (located in the Fee Schedule > Long Description) for any procedure added to the Treatment Plan located in Patients > Ledger > Treatment Plan.
  [Note: The order in which the treatments will display is determined by the 'Sort Treatment Plans By' popup located in Preferences > Forms > Settings. (Code or Tooth)]

• Treatment Write Off Amount: This will reflect the data as entered/found in the 'Write Off' field (located in the Procedure table of the Treatment Window) for any procedure added to the Treatment Plan located in Patients > Ledger > Treatment Plan.
  [Note: The order in which the treatments will display is determined by the 'Sort Treatment Plans By' popup located in Preferences > Forms > Settings. (Code or Tooth)]