1500-N Arial 9 false 1500.gif -54 13 905 1165 P2Diagnosis 470 796 35 14 P1Diagnosis 470 762 35 14 BillingDentistNumIsTIN 210 961 0 0 BillingDentistNumIsSSN 191 961 0 0 BillingDentistPh78910 759 978 48 14 BillingDentistPh456 719 978 40 14 BillingDentistPh123 680 978 40 14 P6PlaceNumericCode 205 929 28 14 P5PlaceNumericCode 205 895 28 14 P4PlaceNumericCode 205 863 28 14 P3PlaceNumericCode 206 829 28 14 P2PlaceNumericCode 205 796 28 14 P1PlaceNumericCode 206 762 28 14 OtherInsNotExists 591 462 0 0 IsNotOtherAccident 431 428 0 0 IsNotAutoAccident 430 395 0 0 IsNotOccupational 430 362 0 0 PatientIsSingle 370 262 0 0 PatientIsMarried 430 262 0 0 IsPTStudent 491 295 0 0 PriInsAddress2 419 110 250 14 IsStandardClaim 329 161 0 0 IsMedicaidClaim 30 162 0 0 P6Date MM dd yy 122 929 78 14 P5Date MM dd yy 122 895 78 14 P4Date MM dd yy 122 863 78 14 P2Date MM dd yy 122 796 78 14 P1Date MM dd yy 122 762 78 14 P3Date MM dd yy 121 829 78 14 BillingDentistZip 701 1026 80 14 BillingDentistST 671 1026 30 14 BillingDentistCity 531 1026 139 14 BillingDentistAddress 531 1010 250 14 BillingDentist 531 994 250 14 TotalFee 620 961 75 14 BillingDentistSSNorTIN 39 959 131 14 P6Fee 598 929 70 14 P6Code 273 929 55 14 P6Date MM dd yy 32 929 77 14 P5Fee 598 895 70 14 P5Code 273 895 55 14 P5Date MM dd yy 32 895 77 14 P4Fee 598 862 70 14 P4Code 273 862 55 14 P4Date MM dd yy 32 863 77 14 P3Fee 598 828 70 14 P3Date MM dd yy 32 829 77 14 P2Fee 598 796 70 14 P2Code 273 796 55 14 P1Fee 598 762 70 14 P1Code 273 762 55 14 P1Date MM dd yy 32 762 77 14 PriInsZip 590 124 79 14 PriInsCity 419 124 140 14 PriInsAddress 419 96 250 14 PriInsCarrierName 419 82 250 14 SubscrPhone 672 293 120 14 PatientAssignment 577 525 210 14 PatientReleaseDate MM/dd/yyyy 384 525 113 14 PatientRelease 78 526 240 14 AccidentST 467 396 30 14 IsOtherAccident 370 428 0 0 IsAutoAccident 370 396 0 0 IsOccupational 370 362 0 0 OtherInsCarrierName 36 460 245 14 OtherInsSubscrIsFemale 261 396 0 0 OtherInsSubscrIsMale 200 396 0 0 OtherInsSubscrDOB MM dd yyyy 42 397 100 14 OtherInsGroupNum 36 358 245 14 OtherInsSubscrLastFirst 36 325 245 14 IsFTStudent 430 295 0 0 EmployerName 528 394 250 14 SubscrIsFemale 771 362 0 0 SubscrIsMale 701 362 0 0 SubscrDOB MM dd yyyy 554 363 100 14 GroupNum 530 327 250 14 SubscrZip 531 294 100 14 SubscrST 760 260 50 14 SubscrCity 530 260 200 14 SubscrAddress 530 225 250 14 RelatIsOther 490 228 0 0 RelatIsChild 440 229 0 0 RelatIsSpouse 400 229 0 0 RelatIsSelf 349 229 0 0 PatientZip 37 293 100 14 PatientST 281 259 30 14 PatientCity 37 258 200 14 PatientAddress 37 226 245 14 SubscrLastFirst 530 192 250 14 PatientIsFemale 490 194 0 0 PatientIsMale 441 195 0 0 PatientDOB MM dd yyyy 333 195 95 14 PatientPhone 169 296 120 14 PatientLastFirst 37 194 245 13 SubscrID 529 161 100 14 P3Code 273 828 55 14 P2Date MM dd yy 32 796 77 14 PriInsST 560 124 30 14 OtherInsExists 540 462 0 0 P3Diagnosis 470 828 35 14 P4Diagnosis 470 863 35 14 P5Diagnosis 470 895 35 14 P6Diagnosis 470 929 35 14 Diagnosis1 52 662 70 14 Diagnosis2 52 695 70 14 Diagnosis3 324 662 70 14 Diagnosis4 325 694 70 14 FixedText 1 615 763 20 14 FixedText 1 615 796 20 14 FixedText 1 615 828 20 14 FixedText 1 615 862 20 14 FixedText 1 615 895 20 14 FixedText 1 615 929 20 14 BillingDentist 256 995 235 14 BillingDentistAddress 256 1009 235 14 BillingDentistCity 256 1023 132 14 BillingDentistST 388 1023 28 14 BillingDentistZip 416 1023 75 14 TreatingDentistSignature 27 1020 142 30 TreatingDentistSigDate 169 1035 74 14 BillingDentistNPI 260 1045 92 14 BillingDentistNPI 531 1045 92 14 P1TreatProvNPI 698 762 100 14 P2TreatProvNPI 698 796 100 14 P3TreatProvNPI 698 828 100 14 P4TreatProvNPI 699 862 100 14 P5TreatProvNPI 699 894 100 14 P6TreatProvNPI 699 928 100 14 P1CodeMod1 340 762 30 16 P1CodeMod2 375 762 30 16 P1CodeMod3 405 762 29 16 P1CodeMod4 434 762 29 16 P2CodeMod1 340 796 30 16 P2CodeMod2 375 796 30 16 P2CodeMod3 405 796 29 16 P2CodeMod4 434 796 29 16 P3CodeMod1 340 827 30 16 P3CodeMod2 375 827 30 16 P3CodeMod3 405 827 29 16 P3CodeMod4 434 827 29 16 P4CodeMod1 340 862 30 16 P4CodeMod2 375 862 30 16 P4CodeMod3 405 862 29 16 P4CodeMod4 434 862 29 16 P5CodeMod1 340 895 30 16 P5CodeMod2 375 895 30 16 P5CodeMod3 405 895 29 16 P5CodeMod4 434 895 29 16 P6CodeMod1 340 929 30 16 P6CodeMod2 375 929 30 16 P6CodeMod3 405 929 29 16 P6CodeMod4 434 929 29 16