Parent File | Name | Number | Package |
---|---|---|---|
THIRD PARTY LIABILITY(#9000041) | DATE OF INJURY | 9000041.0101 | IHS Patient |
Field # | Name | Loc | Type | Details |
---|---|---|---|---|
.01 | DATE OF INJURY | 0;1 | DATE |
|
.02 | INSURER | 0;2 | POINTER TO INSURER FILE (#9999999.18) | INSURER(#9999999.18)
|
.03 | POLICY NUMBER | 0;3 | FREE TEXT |
|
.04 | EFFECTIVE DATE | 0;4 | DATE |
|
.05 | ENDING DATE | 0;5 | DATE |
|
.06 | GROUP NAME | 0;6 | POINTER TO EMPLOYER GROUP INSURANCE FILE (#9999999.77) | EMPLOYER GROUP INSURANCE(#9999999.77)
|
101 | RESPONSIBLE PARTY NAME | 1;1 | FREE TEXT |
|
102 | RESPONSIBLE PARTY SSN | 1;2 | FREE TEXT |
|
103 | PATIENTS ATTORNEY | 1;3 | FREE TEXT |
|
104 | CAUSE OF INJURY | 1;4 | FREE TEXT |
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105 | DESCRIPTION OF INJURY | 1;5 | FREE TEXT |
|
106 | NOTES | 1;6 | FREE TEXT |
|
201 | CLAIM NUMBER | 2;1 | FREE TEXT |
|
202 | DATE LAST WORKED | 2;2 | DATE |
|
203 | DISABILITY START DATE | 2;3 | DATE |
|
204 | DISABILITY END DATE | 2;4 | DATE |
|
205 | WORK RETURN AUTH DATE | 2;5 | DATE |
|
206 | CONTACT INFO | 2;6 | FREE TEXT |
|