POST api/OMR_HCFAForm/add

{
  "exam_ID": "845d5d83-04d4-48a4-87e7-a3b456fea3d5",
  "patient_ID": "e9ce2a36-b9c4-46cb-bdbe-d17bbbe5f021",
  "picaleft": "sample string 3",
  "picaright": "sample string 4",
  "medicare": true,
  "medicaid": true,
  "tricarechampus": true,
  "champva": true,
  "healthplan": true,
  "fecablclung": true,
  "other": true,
  "insurednumber": "sample string 12",
  "patientname": "sample string 13",
  "patientbirthdate": "2026-02-04T02:51:08.0386609+00:00",
  "sexm": true,
  "sexf": true,
  "insuredname": "sample string 17",
  "patientaddress": "sample string 18",
  "relationshipself": true,
  "relationshipspouse": true,
  "relationshipchild": true,
  "relationshipother": true,
  "insuredaddress": "sample string 23",
  "city": "sample string 24",
  "state": "sample string 25",
  "zip": "sample string 26",
  "telephone": "sample string 27",
  "statussingle": true,
  "statusmarried": true,
  "statusother": true,
  "statusemployed": true,
  "statusfullstudent": true,
  "statuspartstudent": true,
  "citY2": "sample string 34",
  "statE2": "sample string 35",
  "ziP2": "sample string 36",
  "telephonE2": "sample string 37",
  "otherinsuredname": "sample string 38",
  "conditionrelated": "sample string 39",
  "insuredpolicygroup": "sample string 40",
  "otherinsuredgroup": "sample string 41",
  "otherinsureddateofbirth": "2026-02-04T02:51:08.0386609+00:00",
  "othersexm": true,
  "othersexf": true,
  "emplnameorschoolname": "sample string 45",
  "programname": "sample string 46",
  "employmentyes": true,
  "employmentno": true,
  "autoaccidentyes": true,
  "autoaccidentnot": true,
  "placestate": "sample string 51",
  "otheraccidentyes": true,
  "otheraccidentnot": true,
  "otherinsureddateofbirtH2": "sample string 54",
  "othersexM2": true,
  "othersexF2": true,
  "emplnameorschoolnamE2": "sample string 57",
  "programnamE2": "sample string 58",
  "isbenefitplanyes": true,
  "isbenefitplanno": true,
  "reservedlocal": "sample string 61",
  "signeD1": "sample string 62",
  "datesigneD1": "sample string 63",
  "signeD2": "sample string 64",
  "dateofcurrent": "2026-02-04T02:51:08.0386609+00:00",
  "firstdate": "sample string 66",
  "workdatefrom": "2026-02-04T02:51:08.0386609+00:00",
  "workdateto": "2026-02-04T02:51:08.0386609+00:00",
  "nameofreferring": "sample string 69",
  "fielD17ASHOT": "sample string 70",
  "fielD17ALONG": "sample string 71",
  "fielD17BNPI": "sample string 72",
  "workdatefroM2": "2026-02-04T02:51:08.0386609+00:00",
  "workdatetO2": "2026-02-04T02:51:08.0386609+00:00",
  "reservedlocaL2": "sample string 75",
  "outsidelabyes": true,
  "outsidelabno": true,
  "chargesfirst": 1.0,
  "chargessecond": 1.0,
  "medicaidcode": "sample string 78",
  "medicaidoroginalno": "sample string 79",
  "priornumber": "sample string 80",
  "relatE1": "sample string 81",
  "relatE2": "sample string 82",
  "relatE3": "sample string 83",
  "relatE4": "sample string 84",
  "relatE5": "sample string 85",
  "dateofservicefroM1": "sample string 86",
  "dateofservicetO1": "sample string 87",
  "placeservicE1": "sample string 88",
  "emG1": "sample string 89",
  "cpthcpcS1": "sample string 90",
  "modifieR1": "sample string 91",
  "diagnosispointeR1": "sample string 92",
  "chargesfirsT1": 1.0,
  "chargesseconD1": 1.0,
  "unitS1": "sample string 93",
  "epsdT1": "sample string 94",
  "quaL1": "sample string 95",
  "renderinG1": "sample string 96",
  "renderingnpI1": "sample string 97",
  "dateofservicefroM2": "sample string 98",
  "dateofservicetO2": "sample string 99",
  "placeservicE2": "sample string 100",
  "emG2": "sample string 101",
  "cpthcpcS2": "sample string 102",
  "modifieR2": "sample string 103",
  "diagnosispointeR2": "sample string 104",
  "chargesfirsT2": 1.0,
  "chargesseconD2": 1.0,
  "unitS2": "sample string 105",
  "epsdT2": "sample string 106",
  "quaL2": "sample string 107",
  "renderinG2": "sample string 108",
  "renderingnpI2": "sample string 109",
  "dateofservicefroM3": "sample string 110",
  "dateofservicetO3": "sample string 111",
  "placeservicE3": "sample string 112",
  "emG3": "sample string 113",
  "cpthcpcS3": "sample string 114",
  "modifieR3": "sample string 115",
  "diagnosispointeR3": "sample string 116",
  "chargesfirsT3": 1.0,
  "chargesseconD3": 1.0,
  "unitS3": "sample string 117",
  "epsdT3": "sample string 118",
  "quaL3": "sample string 119",
  "renderinG3": "sample string 120",
  "renderingnpI3": "sample string 121",
  "dateofservicefroM4": "sample string 122",
  "dateofservicetO4": "sample string 123",
  "placeservicE4": "sample string 124",
  "emG4": "sample string 125",
  "cpthcpcS4": "sample string 126",
  "modifieR4": "sample string 127",
  "diagnosispointeR4": "sample string 128",
  "chargesfirsT4": 1.0,
  "chargesseconD4": 1.0,
  "unitS4": "sample string 129",
  "epsdT4": "sample string 130",
  "quaL4": "sample string 131",
  "renderinG4": "sample string 132",
  "renderingnpI4": "sample string 133",
  "dateofservicefroM5": "sample string 134",
  "dateofservicetO5": "sample string 135",
  "placeservicE5": "sample string 136",
  "emG5": "sample string 137",
  "cpthcpcS5": "sample string 138",
  "modifieR5": "sample string 139",
  "diagnosispointeR5": "sample string 140",
  "chargesfirsT5": 1.0,
  "chargesseconD5": 1.0,
  "unitS5": "sample string 141",
  "epsdT5": "sample string 142",
  "quaL5": "sample string 143",
  "renderinG5": "sample string 144",
  "renderingnpI5": "sample string 145",
  "dateofservicefroM6": "sample string 146",
  "dateofservicetO6": "sample string 147",
  "placeservicE6": "sample string 148",
  "emG6": "sample string 149",
  "cpthcpcS6": "sample string 150",
  "modifieR6": "sample string 151",
  "diagnosispointeR6": "sample string 152",
  "chargesfirsT6": 1.0,
  "chargesseconD6": 1.0,
  "unitS6": "sample string 153",
  "epsdT6": "sample string 154",
  "quaL6": "sample string 155",
  "renderinG6": "sample string 156",
  "renderingnpI6": "sample string 157",
  "federaltaxnumber": "sample string 158",
  "ssncheck": true,
  "eincheck": true,
  "patientaccountno": "sample string 161",
  "acceptassignmentyes": true,
  "acceptassignmentno": true,
  "totalchargefirst": 1.0,
  "totalchargesecond": 1.0,
  "amountpaidfirst": 1.0,
  "amountpaidsecond": 1.0,
  "balanceduefirst": 1.0,
  "balanceduesecond": 1.0,
  "signeD3": "sample string 164",
  "datesigneD3": "sample string 165",
  "serviceinfo": "sample string 166",
  "serviceinfoa": "sample string 167",
  "serviceinfob": "sample string 168",
  "phoneno": "sample string 169",
  "providerinfo": "sample string 170",
  "providerinfoa": "sample string 171",
  "providerinfob": "sample string 172",
  "createddate": "2026-02-04T02:51:08.0386609+00:00",
  "lastupdatedate": "2026-02-04T02:51:08.0386609+00:00",
  "electronicSubmission": "sample string 175",
  "electronicSubmissionStatus": "sample string 176",
  "relatE6": "sample string 177",
  "relatE7": "sample string 178",
  "relatE8": "sample string 179",
  "relatE9": "sample string 180",
  "relatE10": "sample string 181",
  "relatE11": "sample string 182",
  "relatE12": "sample string 183",
  "nameofreferrinG2": "sample string 184",
  "iquaL1": "sample string 185",
  "iquaL2": "sample string 186",
  "iquaL3": "sample string 187",
  "icD1": "sample string 188",
  "icD2": "sample string 189",
  "insuranceDate": "2026-02-04T02:51:08.0386609+00:00"
}

Sample not available.