Overview
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Field Definitions
Field | Type | Required | Description |
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Name and Address Section | |||
Name | Free Text | Yes | The name of the organization responsible for the patient. |
Address | Free Text | Yes | The street address of the organization responsible for the patient. |
City | Free Text | Yes | The city the organization is located in. The field will auto-populate when the Zip Code is entered. However, the field can be edited by typing the name of the city in the space provided. |
State | Free Text | Yes | The state abbreviation where the organization is located. The field will auto-populate when the Zip Code is entered. However, the field can be edited by typing the state abbreviation or selecting an option from the drop down list. |
Zip Code | Free Text (Numeric) | Yes | The five-digit plus 4-digit postal code where the organization is located. |
Tax ID Section | |||
Tax ID Number | Drop Down / Free Text | No | The number an organization uses as its tax identification number: Employer Identification Number (EIN) or Social Security Number (SSN). |
Contact Information Section | |||
Contact Name | The Last, First, and Middle names of the person at the organization who is the primary contact. A Suffix, for example, Sr., Jr., or III, can also be entered, if applicable. | ||
Phone Number | The primary telephone number and extension (if applicable) of the contact at the organization. | ||
Fax Number | The primary facsimile number and extension (if applicable) of the contact at the organization. |