????!@&@Z"ArialZ"ArialGz?tV?㥛 ?K7A`?XZ"Arial/$@K7A@x&1?Mb?01Z"Arial/$@v#@㥛 ?Mb?XdTimes New Roman(\@K7A@jt?K7A`?Z"Arialy&1?nJ@MbX?MbX?%02mZ"ArialDl?nJ@\(\?MbX?%02DZ"ArialS?nJ@㥛 ?MbX?%YZ"Arial/$?nJ@MbX?MbX?%02mZ"ArialtV?nJ@\(\?MbX?%02DZ"Arial^I +?nJ@㥛 ?MbX?%YZ"Arial@nJ@?MbX?Z"Arial/$@nJ@?MbX?Z"Arial^I + @nJ@?MbX?Z"Arial/$@nJ@MbX?MbX?ZZ"Arial@nJ@MbX?MbX?[Z"Arial^I @nJ@MbX?MbX?Z"Arial@nJ@MbX?MbX?Z"Arial/$@nJ@MbX?MbX?%dZ"ArialnJ@nJ@MbX?MbX?%02c$Z"Arial/$@nJ@x&1?MbX?if [Claim Detail - Anesthesia Minutes] = "0" then [Claim Detail - Units] else [Claim Detail - Anesthesia Minutes] endif Z"ArialK7A@/$@K7A`?㥛 ?Z"Arial@/$@5^I ?㥛 ?@Z"Arial@nJ@5^I ?㥛 ? Z"Arialy&1?^I @sh|? @K7A`?if [Claim Detail - Unique Type of Service] = "J" then [Claim Detail - Notes] else "" endifdTimes New RomanK7A@nJ@㥛 ?K7A`?Z"Arialy&1?/$@MbX?MbX?%02mZ"ArialDl?/$@\(\?MbX?%02DZ"ArialS?/$@㥛 ?MbX?%YZ"Arial/$?/$@MbX?MbX?%02mZ"ArialtV?/$@\(\?MbX?%02DZ"Arial^I +?/$@㥛 ?MbX?%YZ"Arial@/$@?MbX?Z"Arial/$@/$@?MbX?Z"Arial^I + @/$@?MbX?Z"Arial/$@/$@MbX?MbX?ZZ"Arial@/$@MbX?MbX?[Z"Arial^I @/$@MbX?MbX?Z"Arial@/$@MbX?MbX?Z"Arial/$@/$@MbX?MbX?%dZ"ArialnJ@/$@MbX?MbX?%02c$Z"Arial/$@/$@MbX?MbX?if [Claim Detail - Anesthesia Minutes] = "0" then [Claim Detail - Units] else [Claim Detail - Anesthesia Minutes] endif Z"ArialK7A@/$@Mb?㥛 ?Z"Arial@/$@5^I ?㥛 ?@Z"Arial@h|?@5^I ?㥛 ? Z"Arialy&1? ףp= @^I + @K7A`?if [Claim Detail - Unique Type of Service] = "J" then [Claim Detail - Notes] else "" endifdTimes New RomanK7A@/$@㥛 ?K7A`?Z"Arialy&1?㥛 p @MbX?MbX?%02mZ"ArialDl?h|?u @\(\?MbX?%02DZ"ArialS?h|?u @㥛 ?MbX?%YZ"Arial/$?h|?u @MbX?MbX?%02mZ"ArialtV?h|?u @\(\?MbX?%02DZ"Arial^I +?h|?u @㥛 ?MbX?%YZ"Arial@h|?u @?MbX?Z"Arial/$@h|?u @?MbX?Z"Arial^I + @h|?u @?MbX?Z"Arial/$@h|?u @MbX?MbX?ZZ"Arial@h|?u @MbX?MbX?[Z"Arial^I @h|?u @MbX?MbX?Z"Arial@h|?u @MbX?MbX?Z"Arial/$@h|?u @MbX?MbX?%dZ"ArialnJ@h|?u @MbX?MbX?%02c$Z"Arial/$@h|?u @Mb?MbX?if [Claim Detail - Anesthesia Minutes] = "0" then [Claim Detail - Units] else [Claim Detail - Anesthesia Minutes] endif Z"ArialK7A@L7A`% @Mb?㥛 ?Z"Arial@L7A`% @5^I ?㥛 ?@Z"Arial@h|?u @5^I ?㥛 ? Z"Arialy&1?㥛 0 @^I + @K7A`?if [Claim Detail - Unique Type of Service] = "J" then [Claim Detail - Notes] else "" endifdTimes New RomanK7A@h|?u @㥛 ?K7A`?Z"Arialy&1?L7A`%!@MbX?MbX?%02mZ"ArialDl?L7A`%!@\(\?MbX?%02DZ"ArialS?L7A`%!@㥛 ?MbX?%YZ"Arial/$?L7A`%!@MbX?MbX?%02mZ"ArialtV?L7A`%!@\(\?MbX?%02DZ"Arial^I +?L7A`%!@㥛 ?MbX?%YZ"Arial@L7A`%!@?MbX?Z"Arial/$@L7A`%!@?MbX?Z"Arial^I + @L7A`%!@?MbX?Z"Arial/$@L7A`%!@MbX?MbX?ZZ"Arial@L7A`%!@MbX?MbX?[Z"Arial^I @L7A`%!@MbX?MbX?Z"Arial@L7A`%!@MbX?MbX?Z"Arial/$@L7A`%!@MbX?MbX?%dZ"ArialnJ@L7A`%!@MbX?MbX?%02c$Z"Arial/$@L7A`%!@x&1?MbX?if [Claim Detail - Anesthesia Minutes] = "0" then [Claim Detail - Units] else [Claim Detail - Anesthesia Minutes] endif Z"ArialK7A@L7A` @Mb?㥛 ?Z"Arial@L7A` @5^I ?㥛 ?@Z"Arial@h|?5!@5^I ?㥛 ? Z"Arialy&1?v @^I + @K7A`?if [Claim Detail - Unique Type of Service] = "J" then [Claim Detail - Notes] else "" endifdTimes New RomanK7A@L7A`%!@㥛 ?K7A`?Z"Arialy&1?n!@MbX?MbX?%02mZ"ArialDl?n!@\(\?MbX?%02DZ"ArialS?n!@㥛 ?MbX?%YZ"Arial/$?n!@MbX?MbX?%02mZ"ArialtV?n!@\(\?MbX?%02DZ"Arial^I +?n!@㥛 ?MbX?%YZ"Arial@n!@?MbX?Z"Arial/$@n!@?MbX?Z"Arial^I + @n!@?MbX?Z"Arial/$@n!@MbX?MbX?ZZ"Arial@n!@MbX?MbX?[Z"Arial^I @n!@MbX?MbX?Z"Arial@n!@MbX?MbX?Z"Arial/$@n!@MbX?MbX?%dZ"ArialnJ@n!@MbX?MbX?%02c$Z"Arial/$@n!@MbX?MbX?if [Claim Detail - Anesthesia Minutes] = "0" then [Claim Detail - Units] else [Claim Detail - Anesthesia Minutes] endif Z"ArialK7A@n!@Mb?㥛 ?Z"Arial@n!@5^I ?㥛 ?@Z"Arial@v!@5^I ?㥛 ? Z"Arialy&1?Q!@^I + @K7A`?if [Claim Detail - Unique Type of Service] = "J" then [Claim Detail - Notes] else "" endifdTimes New RomanK7A@n!@㥛 ?K7A`?Z"Arialy&1?"@MbX?MbX?%02mZ"ArialDl?"@\(\?MbX?%02DZ"ArialS?"@㥛 ?MbX?%YZ"Arial/$?"@MbX?MbX?%02mZ"ArialtV?"@\(\?MbX?%02DZ"Arial^I +?"@㥛 ?MbX?%YZ"Arial@"@?MbX?Z"Arial/$@"@?MbX?Z"Arial^I + @"@?MbX?Z"Arial/$@"@MbX?MbX?ZZ"Arial@"@MbX?MbX?[Z"Arial^I @"@MbX?MbX?Z"Arial@"@MbX?MbX?Z"Arial/$@"@MbX?MbX?%dZ"ArialnJ@"@MbX?MbX?%02c$Z"Arial/$@"@x&1?MbX?if [Claim Detail - Anesthesia Minutes] = "0" then [Claim Detail - Units] else [Claim Detail - Anesthesia Minutes] endif Z"ArialK7A@h|?5"@Mb?㥛 ?Z"Arial(\@@"@5^I ?㥛 ?@Z"Arial(\@n"@5^I ?㥛 ? Z"Arialy&1?㥛 0"@^I + @K7A`?if [Claim Detail - Unique Type of Service] = "J" then [Claim Detail - Notes] else "" endifdTimes New RomanK7A@"@㥛 ?K7A`?cZ"ArialE@v#@y&1?Mb?%dcZ"Arial ףp= @v#@Q?Mb?%02cdZ"Arialn@v#@y&1?Mb?%ddZ"Arial@v#@Q?Mb?%02ceZ"Arial@v#@?Mb?%deZ"Arial9v@v#@x&1?Mb?%02c Z"ArialQ@v#@y&1?Mb?tZ"Arial?"~$@?Mb?%02m %02D %YZ"Arial@K7A`$@/$@K7A`?[Practice City] " " [Practice State] " " [Practice Zip Code]Z"ArialK7A`@n#@5^I ?K7A`?/Z"Arial@5^I ?@MbX?0Z"Arial@y&1?@y&1?4Z"Arialy&1?tV?/$@Mb?DashOnly [Patient Last Name] NoStrip ", " NoStripEnd [Patient First Name] NoStrip ", " NoStripEnd [Patient Middle Initial] DashOnlyEndZ"Arial/$ @tV?MbX?㥛 ?%02mZ"Arial @tV?MbX?㥛 ?%02DZ"ArialtV@tV?y&1?㥛 ?%YEZ"Arial^I @tV?㥛 ?Mb?FZ"Arial^I @tV?q= ףp?Mb?Z"Arialy&1?E@^I +@Mb?Z"Arialy&1?"~j@/$@Mb?Z"ArialQ@"~j@x&1?Mb?Z"Arialy&1?^I +@ףp= ?Mb?)Z"Arialx&1?n @@Mb?if [Secondary Insurance Name] <> "" then [Secondary Insured Last Name] " " [Secondary Insured First Name] else "" endifGZ"Arialn @/$ @㥛 ?Mb?HZ"ArialnJ@/$ @q= ףp?Mb?Z"ArialtV@"~j@㥛 ?Mb?if [Secondary Insurance Name] <> "" and [Secondary Insured Sex] = "M" then "X" else "" endifZ"Arial@"~j@㥛 ?Mb?if [Secondary Insurance Name] <> "" and [Secondary Insured Sex] = "F" then "X" else "" endifZ"Arialn @^I +@㥛 ?Mb?if [Box - Auto Accident] = "X" then "X" endifZ"ArialnJ@^I +@㥛 ?Mb?if [Box - Auto Accident] <> "X" then "X" endifZ"ArialK7A@^I +@?Mb?if [Box - Auto Accident] = "X" then [Accident State] endifZ"Arialn @"~@㥛 ?Mb?if [Box - Other Accident] = "X" then "X" endifZ"ArialnJ@"~@㥛 ?Mb?if [Box - Other Accident] <> "X" then "X" endifCZ"Arialn @@ףp= ?Mb?-Z"Arial@/$@^I +@Mb?if [Primary Insurance Name] = "FL MEDICARE" and [CLIA Number] <> "" then [CLIA Number] else [Provider Custom Field 1] endifwZ"ArialMbX?nJ@/$?Mb?yZ"ArialMbX?/$@/$?Mb?{Z"Arial @nJ@/$?Mb?}Z"Arial @/$@/$?Mb?Z"Arial@/$$@/$@K7A`?[Practice Address Line 1] [Practice Address Line 2]Z"Arial?^I +@jt?Mb? Z"Arial(\u@Zd;$@MbX?㥛 ?Z"Arialy&1?@@K7A`?[Referring Physician First Name] " " [Referring Physician Last Name]Z"Arial@Q#@/$@K7A`?DashOnly [Practice Name] DashOnlyEnd!Z"Arial@^I +@5^I ?Mb?if [Secondary Insurance Name] = "FL MEDICARE" then [Secondary Insured Phone] else [Primary Insured Phone] endif'Z"Arial@^I +@5^I ?Mb?if [Secondary Insurance Name] = "FL MEDICARE" then [Secondary Insured Zip Code] else [Primary Insured Zip Code] endif!Z"ArialK7A`@"~j@x&1?Mb?if [Secondary Insurance Name] = "FL MEDICARE" then [Secondary Insured State] else [Primary Insured State] endifZ"Arial@"~j@@Mb?if [Secondary Insurance Name] = "FL MEDICARE" then [Secondary Insured City] else [Primary Insured City] endif Z"Arialy&1?/$ @@Mb?if [Secondary Insurance Name] <> "" then [Secondary Insurance ID Number] else "NONE" endif Z"ArialtV?"~j@jt?㥛 ?if [Secondary Insurance Name] <> "" then [Secondary Insured Birth Date] else "" endif%Y Z"Arialx&1?"~j@MbX?㥛 ?if [Secondary Insurance Name] <> "" then [Secondary Insured Birth Date] else "" endif%02m Z"Arial5^I ?"~j@MbX?㥛 ?if [Secondary Insurance Name] <> "" then [Secondary Insured Birth Date] else "" endif%02DZ"Arialy&1?n@@@Mb?if [Secondary Insurance Name] <> "" then [Secondary Insurance Name] else "" endifZ"Arialsh|? @n@@/$?Mb?if [Secondary Insurance Name] = "FL MEDICARE" then [Primary Insurance ID Number] else "" endifx1Courier New@"~@@Mb?if [Primary Insurance Type] = "G" and [Secondary Insurance Type] <> "D" and [Secondary Insurance Type] <> "E" and [Secondary Insurance Type] <> "F" and [Secondary Insurance Medigap ID] <> "" then [Secondary Insurance Medigap ID] elseif [Primary Insurance Type] = "G" and [Secondary Insurance Type] <> "D" and [Secondary Insurance Type] <> "E" and [Secondary Insurance Type] <> "F" and [Secondary Insurance Medigap ID] = "" then [Secondary Insurance Name] endif2Z"Arial@Zd;$@y&1?K7A`?if [Provider Group National Provider ID] <> "" then [Provider Group National Provider ID] else [Provider National Provider ID] endifZ"Arial/$ @"~@x&1?Mb?if [Class Findings] = "Y" then "9F" elseif [Primary Insurance Name] = "FL MEDICAID" and [Referring Physician Insurance Code 2] = "" then "" elseif [Primary Insurance Name] = "FL MEDICAID" then "1D" else "" endifZ"Arialn @"~@tV?Mb?)Z"Arialn@@Zd;$@?㥛 ?if [Primary Insurance Practice ID] = "" then [Primary Insurance Provider ID] else [Primary Insurance Practice ID] endif Z"Arial@n#@tV@K7A`?if [Claim Detail - Place of Service] = "11" then [Practice Name] else [Facility Name] endif]Z"Arial@/$$@tV@K7A`?if [Claim Detail - Place of Service] = "11" then [Provider Address Line 1] " " [Provider Address Line 2] else [Facility Address Line 1] " " [Facility Address Line 2] endifgZ"Arial@K7A`$@tV@K7A`?if [Claim Detail - Place of Service] = "11" then [Provider City] " " [Provider State] " " [Provider Zip Code] else [Facility City] " " [Facility State] " " [Facility Zip Code] endif Z"Arialx&1?/$U$@/$@Mb?Z"Arial㥛 ?tV?㥛 ?K7A`?if [Secondary Insurance Name] = "FL MEDICARE" then "X" else "" endif-Z"Arial@)\(?^I +@Mb?if [Secondary Insurance Name] = "FL MEDICARE" then [Secondary Insurance ID Number] else [Primary Insurance ID Number] endifpZ"Arial@tV?n@Mb?if [Secondary Insurance Name] = "FL MEDICARE" then [Secondary Insured Last Name] ", " [Secondary Insured First Name] else [Primary Insured Last Name] ", " [Primary Insured First Name] endif3Z"Arial@E@n@Mb?if [Secondary Insurance Name] = "FL MEDICARE" then [Secondary Insured Address Line 1] else [Primary Insured Address Line 1] endifnZ"ArialQ @E@K7A`?Mb?oZ"Arial ףp= @E@㥛 ?Mb?pZ"Arial9v@E@K7A`?Mb?qZ"Arial9v@E@Mb?Mb?PZ"Arial@n @MbX?㥛 ?%02mPZ"Arialh|?@n @MbX?㥛 ?%02DPZ"Arial"~@n @jt?㥛 ?%YZ"Arial/$@/$ @㥛 ?Mb?if [Primary Insured Sex] = "M" then "X" endifZ"ArialK7A@/$ @㥛 ?Mb?if [Primary Insured Sex] = "F" then "X" endifZ"Arial^I @n@@㥛 ?Mb?if [Secondary Insurance Indicator] = "Y" then "X" endifZ"Arialn@n@@㥛 ?Mb?if [Secondary Insurance Indicator] <> "Y" then "X" endiftZ"Arial@h|?@?Mb?%02m %02D %YZ"ArialtV?h|?@n@Mb?Z"Arial/$@h|?@@Mb? Z"Arial-?v#@^I +?Mb?if [Provider Tax ID] <> "" then [Provider Tax ID] else [Provider Social Security Number] endifZ"Arialףp= ?v#@Mb?Mb?if [Provider Tax ID] = "" and [Provider Social Security Number] <> "" then "X" endifZ"Arial/$@v#@Mb?Mb?if [Provider Tax ID] <> "" then "X" endif