| Patient Name |
Enter in the format Last, First M |
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| Chart Number: |
Disregard this field |
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| Responsible Party Name |
Enter in the format Last, First M |
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| Apt/Ste# |
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Enter the apartment or suite number |
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| Address |
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Enter the patient's address |
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| Sex |
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Enter the patient's gender |
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| Title: |
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Enter the patient's title |
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| Home Phone |
This field will automatically default to the most common area code based on the zip code. |
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Enter the phone number without using any dashes (for example: 1234567890 will appear as (123) 456-7890 |
| Work Phone: |
(Optional)This field will automatically default to the most common area code based on the zip code. |
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Enter the phone number without using any dashes (for example: 1234567890 will appear as (123) 456-7890 |
| Other: |
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(Optional)This field will automatically default to the most common area code based on the zip code. |
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Enter the phone number without using any dashes (for example: 1234567890 will appear as (123) 456-7890 |
| Email: |
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(Optional)Enter the patient's e-mail |
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| Marital Status: |
Enter the patient's marital status from the drop down list. |
| Date of Birth |
Enter the patient's date of birth in a MMDDYYYY format. |
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This field will automatically format to MM/DD/YYYY format. |
| Deceased: |
Disregard this field |
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| Financial Class: |
This field associates an allowable fee schedule with the patient's charges |
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Only carriers for which your practice is in network will appear on this list |
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Select "CM" if you do not see the patient's insurance carrier on the list |
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Select "SP" for full fee self-pay patients |
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| Provider profile: |
Select the appropriate provider or provider/supervisor profile |
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Be sure to select the provider or provider/supervisor profile that matches existing authorizations |
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If you need to add providers or provider/supervisor profiles, please contact Mark Gallegos |
| Employer: |
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(Optional) |
| HIPAA Relationship: |
Disregard this field |
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| Insurance Order: |
Disregard this field |
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| Click "Save" |
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icon located on the far left of the toolbar.
