| Name | Description | Type | Additional information |
|---|---|---|---|
| SubmitterFirstName | string |
None. |
|
| SubmitterLastName | string |
None. |
|
| RelationshipToPatient | string |
None. |
|
| SubmitterEmail | string |
None. |
|
| SubmitterAddress | string |
None. |
|
| SubmitterCity | string |
None. |
|
| SubmitterState | string |
None. |
|
| SubmitterZipCode | string |
None. |
|
| HomePhone | string |
None. |
|
| CellPhone | string |
None. |
|
| Referral | string |
None. |
|
| PatientFirstName | string |
None. |
|
| PatientLastName | string |
None. |
|
| PatientDOB | string |
None. |
|
| PatientMaritalStatus | string |
None. |
|
| PatientAddress | string |
None. |
|
| PatientCity | string |
None. |
|
| PatientState | string |
None. |
|
| PatientZipCode | string |
None. |
|
| PaymentMethod | string |
None. |
|
| Guarantor | string |
None. |
|
| InsName | string |
None. |
|
| InsPhone | string |
None. |
|
| SubscriberName | string |
None. |
|
| SubscriberDOB | string |
None. |
|
| RelToPatient | string |
None. |
|
| SubscriberEmployer | string |
None. |
|
| MemberID | string |
None. |