Spaces:
Running
Running
| Main Field Sub Field | |
| Personal | |
| General Info | |
| Patient ID Dropdown Data Fields | |
| Last Name | |
| First Name | |
| Middle Name | |
| Preferred Name | |
| Suffix | |
| Birthdate | |
| Account Number | |
| Customer Type | |
| Facility Master | |
| Facility Resident | |
| Patient | |
| Prior System Key | |
| Facility Search Field | |
| Billing Address | |
| Address | |
| Address | |
| City | |
| State | |
| County | |
| Country | |
| Postal Code | |
| _____-____ | |
| Custom Fields | |
| S&S and Elig and Deduct | |
| Incont Campaign | |
| Successful | |
| Unsuccessful | |
| Compress Campaign | |
| Successful | |
| Unsuccessful | |
| Mailer - Incont Campaign | |
| Successful | |
| Unsuccessful | |
| Clamp On Rail Campaign | |
| Successful | |
| Unsuccessful | |
| BP Machines Campaign | |
| Successful | |
| Unsuccessful | |
| Extended Info | |
| Hold Account | |
| Hold Billing Statements | |
| HIPAA Signature on file | |
| Discount Percent % | |
| Tax Zone | |
| Search Field | |
| Branch Office | |
| New Hampshire Medical Supply | |
| NHMS BRA | |
| NHMS BSC | |
| Account Group | |
| "1-9 | |
| A-Z" | |
| PT Security Group | |
| PCAs Name list | |
| User 1 | |
| Text Field | |
| Patient Hub Email Address | |
| Not Invited | |
| Place of Service | |
| 12 Home to 17 Walkin Retail clinic | |
| Date of Admission | |
| Date Selection | |
| Date of Discharge | |
| Date Selection | |
| Delivery Addresses | |
| Active Addresses Only | |
| Address | |
| City | |
| State | |
| County | |
| Country | |
| Postal Code | |
| _____-____ | |
| Description | |
| Text Field | |
| Phone | |
| (___) ___-____ | |
| Zone (None) | |
| create form |