Patient Last NameExtract the patient last name...
Patient First NameExtract the patient first name...
Patient Middle NameExtract the patient middle name or initial...
Date of BirthExtract the date of birth. Return in YYYY-MM-DD fo...
GenderExtract gender: Male, Female, Other, Prefer not to...
SSNExtract the Social Security Number (may be partial...
AddressExtract the full street address...
CityExtract the city...
StateExtract the state...
ZIP CodeExtract the ZIP code...
Home PhoneExtract the home phone number...
Cell PhoneExtract the cell/mobile phone number...
EmailExtract the email address...
Emergency Contact NameExtract the emergency contact name...
Emergency Contact PhoneExtract the emergency contact phone number...
Emergency Contact RelationshipExtract the relationship to emergency contact...
Primary InsuranceExtract the primary insurance company name...
Primary Member IDExtract the primary insurance member/subscriber ID...
Primary Group NumberExtract the primary insurance group number...
Primary PolicyholderExtract the primary policyholder name if different...
Primary Policyholder DOBExtract the primary policyholder DOB. Return in YY...
Secondary InsuranceExtract secondary insurance name if present...
Secondary Member IDExtract secondary insurance member ID...
EmployerExtract the employer name...
Employer PhoneExtract the employer phone number...
Signature PresentIs the patient signature present? Yes or No...
Signature DateExtract the signature date. Return in YYYY-MM-DD f...