IBDEI019 ; ; 18-MAR-1994
;;Version 2.0 ; INTEGRATED BILLING ;; 21-MAR-94
Q:'DIFQR(358.5) F I=1:2 S X=$T(Q+I) Q:X="" S Y=$E($T(Q+I+1),4,999),X=$E(X,4,999) S:$A(Y)=126 I=I+1,Y=$E(Y,2,999)_$E($T(Q+I+1),5,99) S:$A(Y)=61 Y=$E(Y,2,999) X NO E S @X=Y
Q Q
;;^UTILITY(U,$J,358.5,269,0)
;;=COMMENTS^71^2^^^^^^^0^8^4^2^132
;;^UTILITY(U,$J,358.5,275,0)
;;=PROGRESS NOTES^73^2^^^Progress Notes: ( ) Attached ( ) See Chart^^^^0^0^9^2^132
;;^UTILITY(U,$J,358.5,276,0)
;;=SIGNATURE^73^3
;;^UTILITY(U,$J,358.5,276,2,0)
;;=^357.52I^1^1
;;^UTILITY(U,$J,358.5,276,2,1,0)
;;=Provider Signature:^^^30^9^10^50^50^1
;;^UTILITY(U,$J,358.5,277,0)
;;=SIGNATURE^74^3
;;^UTILITY(U,$J,358.5,277,2,0)
;;=^357.52I^1^1
;;^UTILITY(U,$J,358.5,277,2,1,0)
;;=Signature of Provider^^^60^4^3^60^40^1
;;^UTILITY(U,$J,358.5,278,0)
;;=CLINIC^74^5
;;^UTILITY(U,$J,358.5,278,2,0)
;;=^357.52I^1^1
;;^UTILITY(U,$J,358.5,278,2,1,0)
;;=Clinic:^^^0^3^3^8^30^1
;;^UTILITY(U,$J,358.5,279,0)
;;=ADDRESS LINE 1^75^9^^1
;;^UTILITY(U,$J,358.5,279,2,0)
;;=^357.52I^1^1
;;^UTILITY(U,$J,358.5,279,2,1,0)
;;=Address:^^U^1^1^2^1^45^1
;;^UTILITY(U,$J,358.5,280,0)
;;=TELEPHONE^75^16
;;^UTILITY(U,$J,358.5,280,2,0)
;;=^357.52I^1^1
;;^UTILITY(U,$J,358.5,280,2,1,0)
;;=Telephone:^^^15^1^1^26^20^1
;;^UTILITY(U,$J,358.5,281,0)
;;=ADDRESS LINE 2^75^9^^2
;;^UTILITY(U,$J,358.5,281,2,0)
;;=^357.52I^1^1
;;^UTILITY(U,$J,358.5,281,2,1,0)
;;=ADDRESS LINE 2^^I^^^3^1^45^1
;;^UTILITY(U,$J,358.5,282,0)
;;=ADDRESS LINE 3^75^9^^3
;;^UTILITY(U,$J,358.5,282,2,0)
;;=^357.52I^1^1
;;^UTILITY(U,$J,358.5,282,2,1,0)
;;=ADDRESS LINE 3^^I^^^4^1^45^1
;;^UTILITY(U,$J,358.5,283,0)
;;=ADDRESS LINE 4^75^9^1^4
;;^UTILITY(U,$J,358.5,283,2,0)
;;=^357.52I^1^1
;;^UTILITY(U,$J,358.5,283,2,1,0)
;;=ADDRESS LINE 4^^I^^^5^1^45^1
;;^UTILITY(U,$J,358.5,284,0)
;;=INSURED?^75^12
;;^UTILITY(U,$J,358.5,284,2,0)
;;=^357.52I^1^1
;;^UTILITY(U,$J,358.5,284,2,1,0)
;;=Insurance:^^U^1^6^6^12^7^1
;;^UTILITY(U,$J,358.5,285,0)
;;=INSURANCE 1^75^13^0^1
;;^UTILITY(U,$J,358.5,285,2,0)
;;=^357.52I^2^2
;;^UTILITY(U,$J,358.5,285,2,1,0)
;;=COMPANY^^I^^^7^1^28^1
;;^UTILITY(U,$J,358.5,285,2,2,0)
;;=Policy Number:^^U^30^6^7^30^19^3
;;^UTILITY(U,$J,358.5,286,0)
;;=INSURANCE 2^75^13^0^2
;;^UTILITY(U,$J,358.5,286,2,0)
;;=^357.52I^2^2
;;^UTILITY(U,$J,358.5,286,2,1,0)
;;=COMPANY^^I^^^8^1^28^1
;;^UTILITY(U,$J,358.5,286,2,2,0)
;;=POLICY #^^I^^^8^30^19^3
;;^UTILITY(U,$J,358.5,287,0)
;;=INSURANCE 3^75^13^0^3
;;^UTILITY(U,$J,358.5,287,2,0)
;;=^357.52I^2^2
;;^UTILITY(U,$J,358.5,287,2,1,0)
;;=COMPANY^^I^^^9^1^28^1
;;^UTILITY(U,$J,358.5,287,2,2,0)
;;=POLICY #^^I^^^9^30^19^3
;;^UTILITY(U,$J,358.5,288,0)
;;=INSURANCE 4^75^13^1^4
;;^UTILITY(U,$J,358.5,288,2,0)
;;=^357.52I^2^2
;;^UTILITY(U,$J,358.5,288,2,1,0)
;;=COMPANY^^I^^^10^1^28^1
;;^UTILITY(U,$J,358.5,288,2,2,0)
;;=POLICY #^^I^^^10^30^19^3
;;^UTILITY(U,$J,358.5,289,0)
;;=MARITAL STATUS^75^17
;;^UTILITY(U,$J,358.5,289,2,0)
;;=^357.52I^1^1
;;^UTILITY(U,$J,358.5,289,2,1,0)
;;=Marital Status:^^^1^11^11^17^15^1
;;^UTILITY(U,$J,358.5,290,0)
;;=EMPLOYER^75^18
;;^UTILITY(U,$J,358.5,290,2,0)
;;=^357.52I^1^1
;;^UTILITY(U,$J,358.5,290,2,1,0)
;;=Employer:^^U^1^12^13^4^45^1
;;^UTILITY(U,$J,358.5,291,0)
;;=EMPLOYMENT STATUS^75^19
;;^UTILITY(U,$J,358.5,291,2,0)
;;=^357.52I^1^1
;;^UTILITY(U,$J,358.5,291,2,1,0)
;;=Status:^^^20^12^12^28^20^1
;;^UTILITY(U,$J,358.5,292,0)
;;=SPOUSE'S EMPLOYER^75^20
;;^UTILITY(U,$J,358.5,292,2,0)
;;=^357.52I^1^1
;;^UTILITY(U,$J,358.5,292,2,1,0)
;;=Spouse's Employer:^^U^1^14^15^4^45^1
;;^UTILITY(U,$J,358.5,293,0)
;;=VITALS^78^3
;;^UTILITY(U,$J,358.5,293,2,0)
;;=^357.52I^6^5
;;^UTILITY(U,$J,358.5,293,2,1,0)
;;=WT:^^^5^2^2^9^14^1
;;^UTILITY(U,$J,358.5,293,2,2,0)
;;=BP:^^^24^2^2^28^14^1
;;^UTILITY(U,$J,358.5,293,2,3,0)
;;=T:^^^43^2^2^46^14^1
IBDEI019 ; ; 18-MAR-1994
+1 ;;Version 2.0 ; INTEGRATED BILLING ;; 21-MAR-94
+2 IF 'DIFQR(358.5)
QUIT
FOR I=1:2
SET X=$TEXT(Q+I)
IF X=""
QUIT
SET Y=$EXTRACT($TEXT(Q+I+1),4,999)
SET X=$EXTRACT(X,4,999)
IF $ASCII(Y)=126
SET I=I+1
SET Y=$EXTRACT(Y,2,999)_$EXTRACT($TEXT(Q+I+1),5,99)
IF $ASCII(Y)=61
SET Y=$EXTRACT(Y,2,999)
XECUTE NO
IF '$TEST
SET @X=Y
Q QUIT
+1 ;;^UTILITY(U,$J,358.5,269,0)
+2 ;;=COMMENTS^71^2^^^^^^^0^8^4^2^132
+3 ;;^UTILITY(U,$J,358.5,275,0)
+4 ;;=PROGRESS NOTES^73^2^^^Progress Notes: ( ) Attached ( ) See Chart^^^^0^0^9^2^132
+5 ;;^UTILITY(U,$J,358.5,276,0)
+6 ;;=SIGNATURE^73^3
+7 ;;^UTILITY(U,$J,358.5,276,2,0)
+8 ;;=^357.52I^1^1
+9 ;;^UTILITY(U,$J,358.5,276,2,1,0)
+10 ;;=Provider Signature:^^^30^9^10^50^50^1
+11 ;;^UTILITY(U,$J,358.5,277,0)
+12 ;;=SIGNATURE^74^3
+13 ;;^UTILITY(U,$J,358.5,277,2,0)
+14 ;;=^357.52I^1^1
+15 ;;^UTILITY(U,$J,358.5,277,2,1,0)
+16 ;;=Signature of Provider^^^60^4^3^60^40^1
+17 ;;^UTILITY(U,$J,358.5,278,0)
+18 ;;=CLINIC^74^5
+19 ;;^UTILITY(U,$J,358.5,278,2,0)
+20 ;;=^357.52I^1^1
+21 ;;^UTILITY(U,$J,358.5,278,2,1,0)
+22 ;;=Clinic:^^^0^3^3^8^30^1
+23 ;;^UTILITY(U,$J,358.5,279,0)
+24 ;;=ADDRESS LINE 1^75^9^^1
+25 ;;^UTILITY(U,$J,358.5,279,2,0)
+26 ;;=^357.52I^1^1
+27 ;;^UTILITY(U,$J,358.5,279,2,1,0)
+28 ;;=Address:^^U^1^1^2^1^45^1
+29 ;;^UTILITY(U,$J,358.5,280,0)
+30 ;;=TELEPHONE^75^16
+31 ;;^UTILITY(U,$J,358.5,280,2,0)
+32 ;;=^357.52I^1^1
+33 ;;^UTILITY(U,$J,358.5,280,2,1,0)
+34 ;;=Telephone:^^^15^1^1^26^20^1
+35 ;;^UTILITY(U,$J,358.5,281,0)
+36 ;;=ADDRESS LINE 2^75^9^^2
+37 ;;^UTILITY(U,$J,358.5,281,2,0)
+38 ;;=^357.52I^1^1
+39 ;;^UTILITY(U,$J,358.5,281,2,1,0)
+40 ;;=ADDRESS LINE 2^^I^^^3^1^45^1
+41 ;;^UTILITY(U,$J,358.5,282,0)
+42 ;;=ADDRESS LINE 3^75^9^^3
+43 ;;^UTILITY(U,$J,358.5,282,2,0)
+44 ;;=^357.52I^1^1
+45 ;;^UTILITY(U,$J,358.5,282,2,1,0)
+46 ;;=ADDRESS LINE 3^^I^^^4^1^45^1
+47 ;;^UTILITY(U,$J,358.5,283,0)
+48 ;;=ADDRESS LINE 4^75^9^1^4
+49 ;;^UTILITY(U,$J,358.5,283,2,0)
+50 ;;=^357.52I^1^1
+51 ;;^UTILITY(U,$J,358.5,283,2,1,0)
+52 ;;=ADDRESS LINE 4^^I^^^5^1^45^1
+53 ;;^UTILITY(U,$J,358.5,284,0)
+54 ;;=INSURED?^75^12
+55 ;;^UTILITY(U,$J,358.5,284,2,0)
+56 ;;=^357.52I^1^1
+57 ;;^UTILITY(U,$J,358.5,284,2,1,0)
+58 ;;=Insurance:^^U^1^6^6^12^7^1
+59 ;;^UTILITY(U,$J,358.5,285,0)
+60 ;;=INSURANCE 1^75^13^0^1
+61 ;;^UTILITY(U,$J,358.5,285,2,0)
+62 ;;=^357.52I^2^2
+63 ;;^UTILITY(U,$J,358.5,285,2,1,0)
+64 ;;=COMPANY^^I^^^7^1^28^1
+65 ;;^UTILITY(U,$J,358.5,285,2,2,0)
+66 ;;=Policy Number:^^U^30^6^7^30^19^3
+67 ;;^UTILITY(U,$J,358.5,286,0)
+68 ;;=INSURANCE 2^75^13^0^2
+69 ;;^UTILITY(U,$J,358.5,286,2,0)
+70 ;;=^357.52I^2^2
+71 ;;^UTILITY(U,$J,358.5,286,2,1,0)
+72 ;;=COMPANY^^I^^^8^1^28^1
+73 ;;^UTILITY(U,$J,358.5,286,2,2,0)
+74 ;;=POLICY #^^I^^^8^30^19^3
+75 ;;^UTILITY(U,$J,358.5,287,0)
+76 ;;=INSURANCE 3^75^13^0^3
+77 ;;^UTILITY(U,$J,358.5,287,2,0)
+78 ;;=^357.52I^2^2
+79 ;;^UTILITY(U,$J,358.5,287,2,1,0)
+80 ;;=COMPANY^^I^^^9^1^28^1
+81 ;;^UTILITY(U,$J,358.5,287,2,2,0)
+82 ;;=POLICY #^^I^^^9^30^19^3
+83 ;;^UTILITY(U,$J,358.5,288,0)
+84 ;;=INSURANCE 4^75^13^1^4
+85 ;;^UTILITY(U,$J,358.5,288,2,0)
+86 ;;=^357.52I^2^2
+87 ;;^UTILITY(U,$J,358.5,288,2,1,0)
+88 ;;=COMPANY^^I^^^10^1^28^1
+89 ;;^UTILITY(U,$J,358.5,288,2,2,0)
+90 ;;=POLICY #^^I^^^10^30^19^3
+91 ;;^UTILITY(U,$J,358.5,289,0)
+92 ;;=MARITAL STATUS^75^17
+93 ;;^UTILITY(U,$J,358.5,289,2,0)
+94 ;;=^357.52I^1^1
+95 ;;^UTILITY(U,$J,358.5,289,2,1,0)
+96 ;;=Marital Status:^^^1^11^11^17^15^1
+97 ;;^UTILITY(U,$J,358.5,290,0)
+98 ;;=EMPLOYER^75^18
+99 ;;^UTILITY(U,$J,358.5,290,2,0)
+100 ;;=^357.52I^1^1
+101 ;;^UTILITY(U,$J,358.5,290,2,1,0)
+102 ;;=Employer:^^U^1^12^13^4^45^1
+103 ;;^UTILITY(U,$J,358.5,291,0)
+104 ;;=EMPLOYMENT STATUS^75^19
+105 ;;^UTILITY(U,$J,358.5,291,2,0)
+106 ;;=^357.52I^1^1
+107 ;;^UTILITY(U,$J,358.5,291,2,1,0)
+108 ;;=Status:^^^20^12^12^28^20^1
+109 ;;^UTILITY(U,$J,358.5,292,0)
+110 ;;=SPOUSE'S EMPLOYER^75^20
+111 ;;^UTILITY(U,$J,358.5,292,2,0)
+112 ;;=^357.52I^1^1
+113 ;;^UTILITY(U,$J,358.5,292,2,1,0)
+114 ;;=Spouse's Employer:^^U^1^14^15^4^45^1
+115 ;;^UTILITY(U,$J,358.5,293,0)
+116 ;;=VITALS^78^3
+117 ;;^UTILITY(U,$J,358.5,293,2,0)
+118 ;;=^357.52I^6^5
+119 ;;^UTILITY(U,$J,358.5,293,2,1,0)
+120 ;;=WT:^^^5^2^2^9^14^1
+121 ;;^UTILITY(U,$J,358.5,293,2,2,0)
+122 ;;=BP:^^^24^2^2^28^14^1
+123 ;;^UTILITY(U,$J,358.5,293,2,3,0)
+124 ;;=T:^^^43^2^2^46^14^1
