| Name | Description | Type | Additional information |
|---|---|---|---|
| Exam_ID | globally unique identifier |
None. |
|
| Patient_ID | globally unique identifier |
None. |
|
| PICALEFT | string |
None. |
|
| PICARIGHT | string |
None. |
|
| MEDICARE | boolean |
None. |
|
| MEDICAID | boolean |
None. |
|
| TRICARECHAMPUS | boolean |
None. |
|
| CHAMPVA | boolean |
None. |
|
| HEALTHPLAN | boolean |
None. |
|
| FECABLCLUNG | boolean |
None. |
|
| OTHER | boolean |
None. |
|
| INSUREDNUMBER | string |
None. |
|
| PATIENTNAME | string |
None. |
|
| PATIENTBIRTHDATE | date |
None. |
|
| SEXM | boolean |
None. |
|
| SEXF | boolean |
None. |
|
| INSUREDNAME | string |
None. |
|
| PATIENTADDRESS | string |
None. |
|
| RELATIONSHIPSELF | boolean |
None. |
|
| RELATIONSHIPSPOUSE | boolean |
None. |
|
| RELATIONSHIPCHILD | boolean |
None. |
|
| RELATIONSHIPOTHER | boolean |
None. |
|
| INSUREDADDRESS | string |
None. |
|
| CITY | string |
None. |
|
| STATE | string |
None. |
|
| ZIP | string |
None. |
|
| TELEPHONE | string |
None. |
|
| STATUSSINGLE | boolean |
None. |
|
| STATUSMARRIED | boolean |
None. |
|
| STATUSOTHER | boolean |
None. |
|
| STATUSEMPLOYED | boolean |
None. |
|
| STATUSFULLSTUDENT | boolean |
None. |
|
| STATUSPARTSTUDENT | boolean |
None. |
|
| CITY2 | string |
None. |
|
| STATE2 | string |
None. |
|
| ZIP2 | string |
None. |
|
| TELEPHONE2 | string |
None. |
|
| OTHERINSUREDNAME | string |
None. |
|
| CONDITIONRELATED | string |
None. |
|
| INSUREDPOLICYGROUP | string |
None. |
|
| OTHERINSUREDGROUP | string |
None. |
|
| OTHERINSUREDDATEOFBIRTH | date |
None. |
|
| OTHERSEXM | boolean |
None. |
|
| OTHERSEXF | boolean |
None. |
|
| EMPLNAMEORSCHOOLNAME | string |
None. |
|
| PROGRAMNAME | string |
None. |
|
| EMPLOYMENTYES | boolean |
None. |
|
| EMPLOYMENTNO | boolean |
None. |
|
| AUTOACCIDENTYES | boolean |
None. |
|
| AUTOACCIDENTNOT | boolean |
None. |
|
| PLACESTATE | string |
None. |
|
| OTHERACCIDENTYES | boolean |
None. |
|
| OTHERACCIDENTNOT | boolean |
None. |
|
| OTHERINSUREDDATEOFBIRTH2 | string |
None. |
|
| OTHERSEXM2 | boolean |
None. |
|
| OTHERSEXF2 | boolean |
None. |
|
| EMPLNAMEORSCHOOLNAME2 | string |
None. |
|
| PROGRAMNAME2 | string |
None. |
|
| ISBENEFITPLANYES | boolean |
None. |
|
| ISBENEFITPLANNO | boolean |
None. |
|
| RESERVEDLOCAL | string |
None. |
|
| SIGNED1 | string |
None. |
|
| DATESIGNED1 | string |
None. |
|
| SIGNED2 | string |
None. |
|
| DATEOFCURRENT | date |
None. |
|
| FIRSTDATE | string |
None. |
|
| WORKDATEFROM | date |
None. |
|
| WORKDATETO | date |
None. |
|
| NAMEOFREFERRING | string |
None. |
|
| FIELD17ASHOT | string |
None. |
|
| FIELD17ALONG | string |
None. |
|
| FIELD17BNPI | string |
None. |
|
| WORKDATEFROM2 | date |
None. |
|
| WORKDATETO2 | date |
None. |
|
| RESERVEDLOCAL2 | string |
None. |
|
| OUTSIDELABYES | boolean |
None. |
|
| OUTSIDELABNO | boolean |
None. |
|
| CHARGESFIRST | decimal number |
None. |
|
| CHARGESSECOND | decimal number |
None. |
|
| MEDICAIDCODE | string |
None. |
|
| MEDICAIDOROGINALNO | string |
None. |
|
| PRIORNUMBER | string |
None. |
|
| RELATE1 | string |
None. |
|
| RELATE2 | string |
None. |
|
| RELATE3 | string |
None. |
|
| RELATE4 | string |
None. |
|
| RELATE5 | string |
None. |
|
| DATEOFSERVICEFROM1 | string |
None. |
|
| DATEOFSERVICETO1 | string |
None. |
|
| PLACESERVICE1 | string |
None. |
|
| EMG1 | string |
None. |
|
| CPTHCPCS1 | string |
None. |
|
| MODIFIER1 | string |
None. |
|
| DIAGNOSISPOINTER1 | string |
None. |
|
| CHARGESFIRST1 | decimal number |
None. |
|
| CHARGESSECOND1 | decimal number |
None. |
|
| UNITS1 | string |
None. |
|
| EPSDT1 | string |
None. |
|
| QUAL1 | string |
None. |
|
| RENDERING1 | string |
None. |
|
| RENDERINGNPI1 | string |
None. |
|
| DATEOFSERVICEFROM2 | string |
None. |
|
| DATEOFSERVICETO2 | string |
None. |
|
| PLACESERVICE2 | string |
None. |
|
| EMG2 | string |
None. |
|
| CPTHCPCS2 | string |
None. |
|
| MODIFIER2 | string |
None. |
|
| DIAGNOSISPOINTER2 | string |
None. |
|
| CHARGESFIRST2 | decimal number |
None. |
|
| CHARGESSECOND2 | decimal number |
None. |
|
| UNITS2 | string |
None. |
|
| EPSDT2 | string |
None. |
|
| QUAL2 | string |
None. |
|
| RENDERING2 | string |
None. |
|
| RENDERINGNPI2 | string |
None. |
|
| DATEOFSERVICEFROM3 | string |
None. |
|
| DATEOFSERVICETO3 | string |
None. |
|
| PLACESERVICE3 | string |
None. |
|
| EMG3 | string |
None. |
|
| CPTHCPCS3 | string |
None. |
|
| MODIFIER3 | string |
None. |
|
| DIAGNOSISPOINTER3 | string |
None. |
|
| CHARGESFIRST3 | decimal number |
None. |
|
| CHARGESSECOND3 | decimal number |
None. |
|
| UNITS3 | string |
None. |
|
| EPSDT3 | string |
None. |
|
| QUAL3 | string |
None. |
|
| RENDERING3 | string |
None. |
|
| RENDERINGNPI3 | string |
None. |
|
| DATEOFSERVICEFROM4 | string |
None. |
|
| DATEOFSERVICETO4 | string |
None. |
|
| PLACESERVICE4 | string |
None. |
|
| EMG4 | string |
None. |
|
| CPTHCPCS4 | string |
None. |
|
| MODIFIER4 | string |
None. |
|
| DIAGNOSISPOINTER4 | string |
None. |
|
| CHARGESFIRST4 | decimal number |
None. |
|
| CHARGESSECOND4 | decimal number |
None. |
|
| UNITS4 | string |
None. |
|
| EPSDT4 | string |
None. |
|
| QUAL4 | string |
None. |
|
| RENDERING4 | string |
None. |
|
| RENDERINGNPI4 | string |
None. |
|
| DATEOFSERVICEFROM5 | string |
None. |
|
| DATEOFSERVICETO5 | string |
None. |
|
| PLACESERVICE5 | string |
None. |
|
| EMG5 | string |
None. |
|
| CPTHCPCS5 | string |
None. |
|
| MODIFIER5 | string |
None. |
|
| DIAGNOSISPOINTER5 | string |
None. |
|
| CHARGESFIRST5 | decimal number |
None. |
|
| CHARGESSECOND5 | decimal number |
None. |
|
| UNITS5 | string |
None. |
|
| EPSDT5 | string |
None. |
|
| QUAL5 | string |
None. |
|
| RENDERING5 | string |
None. |
|
| RENDERINGNPI5 | string |
None. |
|
| DATEOFSERVICEFROM6 | string |
None. |
|
| DATEOFSERVICETO6 | string |
None. |
|
| PLACESERVICE6 | string |
None. |
|
| EMG6 | string |
None. |
|
| CPTHCPCS6 | string |
None. |
|
| MODIFIER6 | string |
None. |
|
| DIAGNOSISPOINTER6 | string |
None. |
|
| CHARGESFIRST6 | decimal number |
None. |
|
| CHARGESSECOND6 | decimal number |
None. |
|
| UNITS6 | string |
None. |
|
| EPSDT6 | string |
None. |
|
| QUAL6 | string |
None. |
|
| RENDERING6 | string |
None. |
|
| RENDERINGNPI6 | string |
None. |
|
| FEDERALTAXNUMBER | string |
None. |
|
| SSNCHECK | boolean |
None. |
|
| EINCHECK | boolean |
None. |
|
| PATIENTACCOUNTNO | string |
None. |
|
| ACCEPTASSIGNMENTYES | boolean |
None. |
|
| ACCEPTASSIGNMENTNO | boolean |
None. |
|
| TOTALCHARGEFIRST | decimal number |
None. |
|
| TOTALCHARGESECOND | decimal number |
None. |
|
| AMOUNTPAIDFIRST | decimal number |
None. |
|
| AMOUNTPAIDSECOND | decimal number |
None. |
|
| BALANCEDUEFIRST | decimal number |
None. |
|
| BALANCEDUESECOND | decimal number |
None. |
|
| SIGNED3 | string |
None. |
|
| DATESIGNED3 | string |
None. |
|
| SERVICEINFO | string |
None. |
|
| SERVICEINFOA | string |
None. |
|
| SERVICEINFOB | string |
None. |
|
| PHONENO | string |
None. |
|
| PROVIDERINFO | string |
None. |
|
| PROVIDERINFOA | string |
None. |
|
| PROVIDERINFOB | string |
None. |
|
| CREATEDDATE | date |
None. |
|
| LASTUPDATEDATE | date |
None. |
|
| ElectronicSubmission | string |
None. |
|
| ElectronicSubmissionStatus | string |
None. |
|
| RELATE6 | string |
None. |
|
| RELATE7 | string |
None. |
|
| RELATE8 | string |
None. |
|
| RELATE9 | string |
None. |
|
| RELATE10 | string |
None. |
|
| RELATE11 | string |
None. |
|
| RELATE12 | string |
None. |
|
| NAMEOFREFERRING2 | string |
None. |
|
| IQUAL1 | string |
None. |
|
| IQUAL2 | string |
None. |
|
| IQUAL3 | string |
None. |
|
| ICD1 | string |
None. |
|
| ICD2 | string |
None. |
|
| InsuranceDate | date |
None. |