[FORM OPTIONS]
MAXLINES = 6
LINEHEIGHT=0.1667
[END FORM OPTIONS]

[MARGINS]
Top = 0.0
Left = 0.0
Right = 0.0
Bottom = 0.0
[END MARGINS]

[FONTS]
Font 1 = Arial, 6, Normal, Silver
Font 2 = Arial, 6, Bold, Silver
Font 3 = Arial, 6, Italic, Silver
Font 4 = Arial, 11, Bold, Silver
Font 5 = Arial, 5, Normal, Silver
Font 6 = Courier New, 10, Bold
Font 7 = Arial, 6, BOLD, Silver
[END FONTS]

[PATIENT INFORMATION]
[Primary:Company,5.000,0.333,4.000,LEFT,Font 6];
[Primary:Address1,5,0.497,4,Left,Font 6];
[IF Primary:Address2 <> ""]
    [Primary:Address2,5,0.664,4,Left,Font 6];
    [Primary:City + " " + Primary:State + "  " + Primary:Zip,5,0.831,4,Left,Font 6];
[ELSE]
    [Primary:City + " " + Primary:State + "  " + Primary:Zip,5,0.664,4,Left,Font 6];
[ENDIF]
[IF Bill:Ins1_Type = "0"]
    ["X",0.333,1.5,1,Left,Font 6];
[ENDIF]
[IF Bill:Ins1_Type = "1"]
    ["X",1,1.5,1.2,Left,Font 6];
[ENDIF]
[IF Bill:Ins1_Type = "2"]
    ["X",1.719,1.500,1.000,LEFT,Font 6];
[ENDIF]
[IF Bill:Ins1_Type = "3"]
    ["X",2.625,1.5,1,Left,Font 6];
[ENDIF]
[IF Bill:Ins1_Type = "7"]
    ["X",3.32,1.5,1,Left,Font 6];
[ENDIF]
[IF Bill:Ins1_Type = "4"]
    ["X",3.32,1.5,1,Left,Font 6];
[ENDIF]
[IF Bill:Ins1_Type = "5"]
    ["X",4.125,1.5,1,Left,Font 6];
[ENDIF]
[IF Bill:Ins1_Type = "6"]
    ["X",4.75,1.5,1,Left,Font 6];
[ENDIF]
[IF Bill:Ins1_Type = "8"]
    ["X",4.75,1.5,1,Left,Font 6];
[ENDIF]

[Bill:Ins1_ID,5.25,1.5,3,Left,Font 6];
[Patient:LastName + "  " + Patient:FirstName + " " + Patient:Middle,0.333,1.833,2.750,LEFT,Font 6];

[Month(Patient:BirthDate),3.25,1.834,1,Left,Font 6]
[Day(Patient:BirthDate),3.562,1.834,1,Left,Font 6]
[Year(Patient:BirthDate),3.875,1.834,1,Left,Font 6]

[IF Patient:Sex = "M"]
    ["X",4.458,1.833,1.000,LEFT,Font 6];
[ENDIF]
[IF Patient:Sex = "F"]
    ["X",4.96,1.834,1,Left,Font 6];
[ENDIF]
[IF Bill:Ins1_Type <> "0"]
[Guarantor1:LastName + "  " + Guarantor1:FirstName + " " + Guarantor1:Middle ,5.25,1.834,3,Left, Font 6];
[endif]
[Patient:Address1,0.333,2.167,2.75,Left, Font 6]
[IF Bill:Ins1_GRel = "M"]
    ["X",3.53,,1,Left,Font 6]
[ENDIF]
[IF Bill:Ins1_GRel = "S"]
    ["X",4.03,,1,Left,Font 6]
[ENDIF]
[IF Bill:Ins1_GRel = "P"]
    ["X",4.46,,1,Left,Font 6]
[ENDIF]
[IF Bill:Ins1_GRel = "O"]
    ["X",4.96,,1,Left,Font 6]
[ENDIF]
[IF Bill:Ins1_Type <> "0"]
[Guarantor1:Address1,5.250,0.000,2.750,LEFT,Font 6];
[ENDIF]
[Patient:City,0.333,2.5,2.5,Left, Font 6]
[Patient:State,2.875,,1,Left, Font 6]
[IF Patient:Status = "S"]
    ["X",3.72,,1,Left,Font 6]
[ELSE]
    [IF Patient:Status = "M"]
        ["X",4.35,,1,Left,Font 6]
    [ELSE]
        ["X",4.95,,1,Left,Font 6]
    [ENDIF]
[ENDIF]
[IF Bill:Ins1_Type <> "0"]
[Guarantor1:City,5.25,,3,Left, Font 6]
[Guarantor1:State,7.75,,1,Left, Font 6];
[ENDIF]
[Patient:Zip,0.333,2.834,2.5,Left, Font 6]
[Patient:Phone_Home,1.656,,2.5,Left, Font 6]
[IF Patient:Employer <> ""]
    ["X",3.72,,1,Left,Font 6]
[ENDIF]
[IF Patient:School <> ""]
   [IF Patient:Full_Time = True]
        ["X",4.35,,1,Left,Font 6]
    [ELSE]
        ["X",4.95,,1,Left,Font 6]
    [ENDIF]
[ENDIF]
[IF Bill:Ins1_Type <> "0"]
[Guarantor1:Zip,5.25,,2.5,Left, Font 6]
[Guarantor1:Phone_Home,6.656,,2.5,Left, Font 6]
[Bill:Ins1_Group ,5.25,3.167,3,Left, Font 6];
[ELSE]
["NONE",5.250,3.167,3.000,LEFT,Font 6];
[ENDIF]
[IF Bill:Ins1_Type <> "0"]
    [Guarantor2:LastName + " " + Guarantor2:FirstName + " " + Guarantor2:Middle ,0.333,3.167,2.5,Left, Font 6];
    [Bill:Ins2_ID ,0.333,3.5,3,Left, Font 6]
[ENDIF]
[IF Bill:Ins1_Type = "0"]
  [IF BILL:INS2_NAME = "MEDIGAP"]
     [IF BILL:INS2_GREL = "M"]
  ["SAME",0.333,3.167,3,LEFT,FONT 6]
  [BILL:INS2_NAME + " " + bill:ins2_id,0.333,3.500,4.000,LEFT,Font 6]
[ELSE]
    [Guarantor2:LastName + "  " + Guarantor2:FirstName + " " + Guarantor2:Middle ,0.333,3.167,3,Left, Font 6];
    [BILL:INS2_NAME + " " + bILL:INS2_ID,0.333,3.5,4.00,LEFT,FONT 6]
[ENDIF]
[ENDIF]
[ENDIF]
[IF Bill:Acc_Type = "E"]
    ["X",3.72,3.5,1,Left,Font 6]
[ELSE]
    ["X",4.35,3.5,1,Left,Font 6]
[ENDIF]
[IF Bill:Ins1_Type <> "0"]
[Month(Guarantor1:BirthDate),5.625,3.5,1,Left,Font 6]
[Day(Guarantor1:BirthDate),5.937,,1,Left,Font 6]
[Year(Guarantor1:BirthDate),6.25,,1,Left,Font 6]
[IF Guarantor1:Sex = "M"]
    ["X",7.062,,1,Left,Font 6]
[ENDIF]
[IF Guarantor1:Sex = "F"]
    ["X",7.77,,1,Left,Font 6]
[ENDIF]
[endif]
;
[IF Bill:Ins1_Type = "0"]
  [IF BILL:INS2_NAME = "MEDIGAP"]
        [Month(Guarantor2:BirthDate),0.375,3.834,1,Left,Font 6]
        [Day(Guarantor2:BirthDate),0.688,,1,Left,Font 6]
        [Year(Guarantor2:BirthDate),1,,1,Left,Font 6]
     [IF Guarantor2:Sex = "M"]
         ["X",2.02,,1,Left,Font 6]
     [ENDIF]
     [IF Guarantor2:Sex = "F"]
         ["X",2.656,,1,Left,Font 6]
      [ENDIF]
  [endif]
[endif]
[If Bill:Ins1_Type <>"0"]
[if Bill:Ins2_code <>""]
[Month(Guarantor2:BirthDate),0.375,3.834,1,Left,Font 6]
        [Day(Guarantor2:BirthDate),0.688,,1,Left,Font 6]
        [Year(Guarantor2:BirthDate),1,,1,Left,Font 6]
     [IF Guarantor2:Sex = "M"]
         ["X",2.02,,1,Left,Font 6]
     [ENDIF]
     [IF Guarantor2:Sex = "F"]
         ["X",2.656,,1,Left,Font 6]
      [ENDIF]
  [endif]
[endif]
[IF Bill:Acc_Type = "A"]
    ["X",3.72,3.84,1,Left,Font 6]
    [Bill:Acc_State,4.75,,1,Left,Font 6]
[ELSE]
    ["X",4.35,3.84,1,2,Left,Font 6]
[ENDIF]
[IF Bill:Ins1_Type <> "0"]
    [Employer1:Company,5.25,,2.5,Left, Font 6]
[ENDIF]
;
[IF Bill:Ins1_Type <> "0"]
  [if employer2:company <> ""]
    [Employer2:Company,0.333,4.167,2.5,Left, Font 6];
  [ENDIF]
[endif]
[IF Bill:Ins1_Type = "0"]
  [IF BILL:INS2_NAME = "MEDIGAP"]
 [If secondary:OCNA = " "]  
      [secondary:address1 + " " + secondary:city + " " + secondary:state,0.333,4.167,3,LEFT,Font 6]
 [else]
     ["  ",0.333,4.167,3.000,LEFT,Font 6]
 [endif]
[endif]
[endif]


[IF Bill:Acc_Type = "O"]
    ["X",3.72,4.167,1,Left,Font 6];
[ELSE]
    ["X",4.35,4.167,1,Left,Font 6];
[ENDIF]
[if Bill:ins1_Type <> "0"]
[If bill:ins1_Name = ""]
      [Primary:company,5.25,4.167,3,Left,Font 6];
    [Else]
      [Bill:Ins1_Name,5.250,4.167,3.000,LEFT,Font 6];
[endif]
[endif]
[Bill:Local,3.240,4.500,1.906,LEFT,Font 6]

[IF Bill:Ins1_Type <> "0"]
  [if bill:ins2_code <> ""]
    [if bill:ins2_Name <> ""]
        [Bill:Ins2_Name,0.333,4.5,2.5,Left,Font 6]
    [Else]
        [Secondary:Company,0.333,4.5,2.5,Left,Font 6]
    [Endif]
  ["X",5.438,0.000,1.000,LEFT,Font 6];
  [else]
    ["X",5.969,4.5,1.000,LEFT,Font 6];
  [ENDIF]
[endif]
[IF Bill:Ins1_Type = "0"]
   [IF BILL:INS2_NAME = "MEDIGAP"]
        [IF Secondary:OCNA  = ""]
              [secondary:company,0.333,4.5,2.5,Left,Font 6]
        [Else]
              [secondary:OCNA,0.344,4.500,2.500,LEFT,Font 6]
        [endif]
    [Endif]
[endif]

[IF Patient:Sig_Info = True]
    ["Signature on file",1,5.168,2.5,Left,Font 6]
    [{Today},4,,1,Left,Font 6];
[ENDIF]
[IF Patient:Sig_Assign = True]
    ["Signature on file",6.000,5.167,2.188,LEFT,Font 6];
[ENDIF]
[If bill:acc_type <> ""]
    [Month(Bill:acc_Date),0.375,5.5,1,Left,Font 6]
    [Day(Bill:acc_Date),0.688,,1,Left,Font 6]
    [Year(Bill:acc_Date),1.000,0.000,1.000,LEFT,Font 6]
[else]
    [Month(Bill:Sympt_Date),0.375,5.5,1,Left,Font 6]
    [Day(Bill:Sympt_Date),0.688,,1,Left,Font 6]
    [Year(Bill:Sympt_Date),1.000,0.000,1.000,LEFT,Font 6]
[endif]
[Month(Bill:Similar),3.969,5.500,1.000,LEFT,Font 6]
[Day(Bill:Similar),4.32,,1,Left,Font 6]
[Year(Bill:Similar),4.64,,1,Left,Font 6]
[Month(Bill:Work1),5.625,,1,Left,Font 6]
[Day(Bill:Work1),5.937,,1,Left,Font 6]
[Year(Bill:Work1),6.24,,1,Left,Font 6]
[Month(Bill:Work2),7.03,,1,Left,Font 6]
[Day(Bill:Work2),7.344,,1,Left,Font 6]
[Year(Bill:Work2),7.625,0.000,1.000,LEFT,Font 6]
[Referral:Title,0.333,5.833,2.500,LEFT,Font 6]
[Referral:NPI,3.427,5.844,1.740,LEFT,Font 6]

[Month(Bill:Hosp1),5.625,5.834,1,Left,Font 6]
[Day(Bill:Hosp1),5.937,,1,Left,Font 6]
[Year(Bill:Hosp1),6.24,,1,Left,Font 6]
[Month(Bill:Hosp2),7.03,,1,Left,Font 6]
[Day(Bill:Hosp2),7.344,,1,Left,Font 6]
[Year(Bill:Hosp2),7.625,,1,Left,Font 6];

[Bill:Local1,0.333,6.167,2.5,Left,Font 6]
[IF Bill:Lab_flag = true]
    ["X",5.437,,1,Left,Font 6]
[Dollars(Bill:Lab),7,,.25,right,Font 6]
[cents(Bill:Lab),7.25,,.25,right,Font 6];
[ELSE]
    ["X",5.968,,1,Left,Font 6];
[ENDIF]
[Bill:Diag1,0.58,6.5,1,Left,Font 6]
[Bill:Diag3,3.33,,1,Left,Font 6]
[Bill:Medicaid,5.25,,1,Left,Font 6]
[Bill:Med_Ref,7,,1,Left,Font 6];

[Bill:Diag2,0.58,6.834,1,Left,Font 6]
[Bill:Diag4,3.333,0.000,1.000,LEFT,Font 6]
[IF Bill:Ins1_Prior <> ""]
   [Bill:Ins1_Prior,5.250,0.000,3.000,LEFT,Font 6]
[ELSE]
   [Facility:Clia,5.250,0.000,3.000,LEFT,Font 6]
[ENDIF]
;
;
;
[END PATIENT INFORMATION]

[SERVICE DETAIL]
[IF Bill:ins1_type="1"]
   ["ZZ",6.698,0.000,0.250,LEFT,Font 6]
   [Practice:taxonomy,7.031,0.000,0.854,LEFT,Font 6];
[ELSE]
   [Detail:Local,7.031,0.000,0.854,LEFT,Font 6];
[ENDIF]
[Month(Detail:Date)+" "+Day(Detail:Date) + " " + Year(Detail:Date),0.354,0.000,1.000,LEFT,Font 6]
[Month(Detail:End_Date)+" "+Day(Detail:End_Date) + " " + Year(Detail:End_Date),1.25,,1,Left, Font 6]
[Detail:Med_POS,2.125,0.000,0.250,LEFT,Font 6]
[If Detail:EMG = True]
[Detail:EMG,2.406,0.000,0.250,LEFT,Font 6]
[ENDIF]
[Detail:Diag,4.75,0.000,1.000,LEFT,Font 6]
[Fee:CPT_Code,2.698,0.000,1.000,LEFT,Font 6]
[Detail:Mod1,3.5,0.000,1.000,LEFT,Font 6]
[Detail:Mod2,3.8,,1,Left,Font 6]
[Detail:Mod3,4.1,,1,Left,Font 6]
[Detail:Mod4,4.4,,1,Left,Font 6]
[Dollars(Detail:Extended),5.2,,0.5,Right,Font 6]
[Cents(Detail:Extended),5.500,0.000,0.500,RIGHT,Font 6]
[dollars(Detail:Units),6.156,0.000,0.354,LEFT,Font 6]
[If cents(detail:units) > .00]
[cents(detail:units),6.250,0.000,0.250,LEFT,Font 6]
[endif]
[Detail:EPSDT,6.416,,0.25,Left, Font 6]
["NPI",6.698,0.000,0.250,LEFT,Font 6]
[Employee:NPI,7.031,0.000,0.854,LEFT,Font 6];
[END SERVICE DETAIL]

[CLAIM TOTAL]
[IF Employee:Tax_ID <> ""]
    [Employee:Tax_ID,0.333,9.5,1.5,Left, Font 6]
    ["X",2.1875,,1,Left, Font 6]
[ELSE]
    [Employee:SS,0.333,9.5,1.5,Left, Font 6]
    ["X",1.937,,1,Left, Font 6]
[ENDIF]
[Patient:Code,2.52,,1.25,Left, Font 6]
[IF Bill:Accept = True]
    ["X",4.063,0.000,1.000,LEFT,Font 6]
[ELSE]
    ["X",4.563,0.000,1.000,LEFT,Font 6]
[ENDIF]
[Dollars({Charges}),5.3125,,0.625,Right,Font 6]
[Cents({Charges}),6,,0.25,Left,Font 6]
[Dollars({Payments}),6.438,0.000,0.500,RIGHT,Font 6]
[Cents({Payments}),6.969,0.000,0.250,LEFT,Font 6]
[if bill:ins1_type <> 0]
[Dollars({Balance}),7.375,,0.5,Right,Font 6]
[Cents({Balance}),7.9375,,0.25,Left,Font 6]
[endif]
;
;
[IF Bill:Ins1_Type = "0"]
     [IF Bill:facility = ""]
          [Practice:Name,2.6,,2.5,Left,Font 6]
     [Else]
          [Facility:Company,2.6,,2.5,Left,Font 6]
     [Endif]
[else]
     [Facility:Company,2.604,0.000,2.500,LEFT,Font 6]
[endif]
[Practice:Name,5.500,0.000,2.500,LEFT,Font 6];
[IF Bill:Ins1_Type = "0"]
  [IF Bill:facility = ""]
     [Practice:Address1,2.604,0.000,2.500,LEFT,Font 6]
  [else] 
     [Facility:Address1,2.6,,2.5,Left,Font 6]
  [Endif]
[else]
     [Facility:Address1,2.6,,2.5,Left,Font 6]
[endif]
[Practice:Address1,5.500,0.000,2.500,LEFT,Font 6];

[Employee:Title,0.354,0.000,2.083,LEFT,Font 6]
[IF Bill:Ins1_Type = "0"]
  [IF Bill:facility = ""]
     [Practice:City + " " +Practice:State + " " + Practice:Zip ,2.6,,2.5,Left,Font 6]
  [else]
     [Facility:City + " " +Facility:State + " " + Facility:Zip ,2.6,,2.5,Left,Font 6]
  [Endif]
[else]
     [Facility:City + " " +Facility:State + " " + Facility:Zip ,2.6,,2.5,Left,Font 6]
[endif]
[Practice:City + " " +Practice:State + " " + Practice:Zip ,5.5,,2.5,Left,Font 6];
[{Today},1.000,0.000,1.438,LEFT,Font 6]
[facility:NPI,2.604,0.000,2.500,LEFT,Font 6]

[Practice:usreclaim3,5.406,0.000,1.990,LEFT,Font 6]
[IF Bill:ins1_type="1"]
   ["ZZ"+Practice:taxonomy,6.631,0.000,1.198,LEFT,Font 6];
[ENDIF
[PRACTICE:PHONE,6.698,9.667,3.000,LEFT,Font 6];
[END CLAIM TOTAL]

[INSURANCE FORM]
[{Image,LEFT.BMP,1.35,5.375,0.125}];
[{Image,DOWN1.BMP,4.5,6.375,0.333}];
[{Box,0.271,1.323,7.938,9.167,1,Black,Silver}]
[{Box,3.167,1.667,0.000,3.000,1,Black,Silver}]
[{Box,5.167,1.333,0.000,9.167,1,Black,Silver}]

[{Box,0.2812,1.667,7.9375,0,1,Black,Silver}]
[{Box,0.2812,2,7.9375,0,1,Black,Silver}]
[{Box,0.2812,2.333,7.9375,0,1,Black,Silver}]
[{Box,0.2812,2.667,2.89,0,1,Black,Silver}]
[{Box,5.1718,2.667,3.0625,0,1,Black,Silver}]
[{Box,0.2812,3,7.9375,0,1,Black,Silver}]

[{Box,0.2812,3.343,2.89,0,1,Black,Silver}]
[{Box,5.1718,3.343,3.0625,0,1,Black,Silver}]
[{Box,0.2812,3.667,2.89,0,1,Black,Silver}]
[{Box,5.1718,3.667,3.0625,0,1,Black,Silver}]
[{Box,0.2812,4,2.89,0,1,Black,Silver}]
[{Box,5.1718,4,3.0625,0,1,Black,Silver}]
[{Box,0.2812,4.333,7.9375,0,1,Black,Silver}]
[{Box,0.2812,4.667,7.9375,0,1,Black,Silver}]
[{Box,0.2812,5.333,7.9375,0,1,Black,Silver}]
[{Box,0.2812,5.667,7.9375,0,1,Black,Silver}]
[{Box,0.2812,6,7.9375,0,1,Black,Silver}]
[{Box,0.2812,6.333,7.9375,0,1,Black,Silver}]
[{Box,5.1718,6.667,3.06,0,1,Black,Silver}]
[{Box,0.271,7.000,4.385,2.333,1,Black,Silver}]
[{Box,5.1718,7,3.06,0,1,Black,Silver}]
[{Box,0.2812,7.11,7.9375,0,1,Black,Silver}]
[{Box,0.281,7.333,7.938,0.000,1,Black,Silver}]
[{Box,1.1875,7.333,0,2,1,Black,Silver}]
[{Box,2.094,7.000,0.000,2.333,1,Black,Silver}]
[{Box,2.391,7,0,2.333,1,Black,Silver}]
[{Box,2.677,7.000,0.000,2.333,1,Black,Silver}]
[{Box,6.104,7.000,0.000,2.333,1,Black,Silver}]
[{Box,6.385,7.000,0.000,2.333,1,Black,Silver}]
[{Box,6.657,7,0,2.333,1,Black,Silver}]
[{Box,6.9375,7,0,2.333,1,Black,Silver}]

[{Box,2.469,9.333,0,1.172,1,Black,Silver}]
[{Box,3.969,9.333,0,0.333,1,Black,Silver}]
[{Box,6.312,9.333,0,0.333,1,Black,Silver}]
[{Box,0.2812,7.667,7.9375,0,1,Black,Silver}]
[{Box,0.2812,8,7.9375,0,1,Black,Silver}]
[{Box,0.281,8.333,7.938,0.000,1,Black,Silver}]
[{Box,0.2812,8.667,7.9375,0,1,Black,Silver}]
[{Box,0.2812,9,7.9375,0,1,Black,Silver}]
[{Box,0.281,9.333,7.938,0.000,1,Black,Silver}]
[{Box,0.281,9.667,7.938,0.000,1,Black,Silver}]
[{Box,0.2812,1.455,0.185,0.185,1,Black,Silver}]
[{Box,1,1.455,0.185,0.185,1,Black,Silver}]
[{Box,1.687,1.455,0.185,0.185,1,Black,Silver}]
[{Box,2.593,1.455,0.185,0.185,1,Black,Silver}]
[{Box,3.312,1.455,0.185,0.185,1,Black,Silver}]
[{Box,4.094,1.455,0.185,0.185,1,Black,Silver}]
[{Box,4.688,1.458,0.188,0.188,1,Black,Silver}]
[{Box,4.406,1.785,0.185,0.185,1,Black,Silver}]
[{Box,4.906,1.785,0.185,0.185,1,Black,Silver}]
[{Box,3.5,2.115,0.185,0.185,1,Black,Silver}]
[{Box,4,2.115,0.185,0.185,1,Black,Silver}]
[{Box,4.406,2.115,0.185,0.185,1,Black,Silver}]
[{Box,4.906,2.115,0.185,0.185,1,Black,Silver}]
[{Box,3.687,2.455,0.185,0.185,1,Black,Silver}]
[{Box,4.297,2.455,0.185,0.185,1,Black,Silver}]
[{Box,4.906,2.455,0.185,0.185,1,Black,Silver}]
[{Box,3.687,2.785,0.185,0.185,1,Black,Silver}]
[{Box,4.297,2.785,0.185,0.185,1,Black,Silver}]
[{Box,4.906,2.785,0.185,0.185,1,Black,Silver}]
[{Box,3.687,3.455,0.185,0.185,1,Black,Silver}]
[{Box,4.297,3.455,0.185,0.185,1,Black,Silver}]
[{Box,7,3.455,0.185,0.185,1,Black,Silver}]
[{Box,7.718,3.455,0.185,0.185,1,Black,Silver}]
[{Box,2,3.785,0.185,0.185,1,Black,Silver}]
[{Box,2.594,3.785,0.185,0.185,1,Black,Silver}]
[{Box,3.687,3.785,0.185,0.185,1,Black,Silver}]
[{Box,4.297,3.785,0.185,0.185,1,Black,Silver}]
[{Box,3.687,4.125,0.185,0.185,1,Black,Silver}]
[{Box,4.297,4.125,0.185,0.185,1,Black,Silver}]
[{Box,5.406,4.455,0.185,0.185,1,Black,Silver}]
[{Box,5.906,4.458,0.188,0.188,1,Black,Silver}]
[{Box,5.406,6.112,0.185,0.185,1,Black,Silver}]
[{Box,5.906,6.112,0.185,0.185,1,Black,Silver}]
[{Box,1.906,9.458,0.188,0.188,1,Black,Silver}]
[{Box,2.156,9.458,0.188,0.188,1,Black,Silver}]
[{Box,4.000,9.510,0.188,0.146,1,Black,Silver}]
[{Box,4.500,9.510,0.167,0.146,1,Black,Silver}]
[{Box,5.750,7.344,0.000,2.000,-1,Black,Silver}]

["HEALTH INSURANCE CLAIM FORM",0.250,0.917,3.000,LEFT,Font 4];
["1.    MEDICARE",0.333,1.35,1,Left,Font 1];
["(Medicare #)",0.5,1.53,1,Left,Font 3];
["MEDICAID",1.225,1.35,1,Left,Font 1];
["(Medicaid #)",1.21,1.53,1,Left,Font 3];
["TRICARE",1.906,1.354,1.000,LEFT,Font 1];
["CHAMPUS",1.906,1.438,1.000,LEFT,Font 1];
["(Sponsor's SSN)",1.906,1.53,1,Left,Font 3];
["CHAMPVA",2.813,1.354,1.000,LEFT,Font 1];
["(Member ID#)",2.781,1.427,1.000,LEFT,Font 3];
["GROUP",3.5,1.35,1,Left,Font 1];
["HEALTH PLAN",3.500,1.438,1.000,LEFT,Font 1];
["(SSN or ID)",3.5,1.53,1,Left,Font 3];
["FECA",4.29,1.35,1,Left,Font 1];
["BLK LUNG",4.29,1.44,1,Left,Font 1];
["(SSN)",4.29,1.53,1,Left,Font 3];
["OTHER",4.875,1.35,1,Left,Font 1];
["(ID)",4.896,1.531,1.000,LEFT,Font 3];
["1a. INSURED'S I.D. NUMBER",5.2,1.35,2,Left,Font 1];
["(FOR PROGRAM IN ITEM 1)",7,1.35,2,Left,Font 1];
["2. PATIENT'S NAME (Last Name, First Name, Middle Initial)",0.333,1.68,3,Left,Font 1];
["3. PATIENT'S BIRTH DATE",3.2,1.68,3,Left,Font 1];
["4. INSURED'S NAME (Last Name, First Name, Middle Initial)",5.2,1.68,3,Left,Font 1];
["SEX",4.656,1.72,1,Left,Font 1];
["MM",3.28,1.77,1,Left,Font 1];
["DD",3.625,1.77,1,Left,Font 1];
["YY",3.937,1.77,1,Left,Font 1];
["M",4.312,1.80,1,Left,Font 1];
["F",4.827,1.80,1,Left,Font 1];
["5. PATIENT'S ADDRESS (No., Street)",0.333,2.01,3,Left,Font 1];
["6. PATIENT RELATIONSHIP TO INSURED",3.2,2.01,3,Left,Font 1];
["7. INSURED ADDRESS (No. Street)",5.2,2.01,3,Left,Font 1];
["Self",3.32,2.17,1,Left,Font 1];
["Spouse",3.71,2.17,1,Left,Font 1];
["Child",4.2,2.17,1,Left,Font 1];
["Other",4.66,2.17,1,Left,Font 1];
["CITY",0.333,2.35,1,Left,Font 1];
["8. PATIENT STATUS",3.2,2.35,1,Left,Font 1];
["CITY",5.2,2.35,1,Left,Font 1];
["STATE",2.85,2.35,1,Left,Font 1];
["STATE",7.55,2.35,1,Left,Font 1];
[{Box,2.8,2.33,0,0.35,1,Black,Silver}];
[{Box,7.5,2.33,0,0.35,1,Black,Silver}];
["Single",3.417,2.500,1.000,LEFT,Font 1];
["Married",3.99,2.5,1,Left,Font 1];
["Other",4.66,2.5,1,Left,Font 1];
["ZIP CODE",0.333,2.68,1,Left,Font 1];
["TELEPHONE (Include Area Code)",1.625,2.68,3,Left,Font 1];
["ZIP CODE",5.2,2.68,1,Left,Font 1];
["TELEPHONE (Include Area Code)",6.437,2.68,3,Left,Font 1];
[{Box,1.594,2.66,0,0.34,1,Black,Silver}];
[{Box,6.406,2.66,0,0.34,1,Black,Silver}];
["Employed",3.28,2.8,1,Left,Font 1];
["Full-Time",3.937,2.8,1,Left,Font 1];
["Part-Time",4.5,2.8,1,Left,Font 1];
["Student",3.937,2.88,1,Left,Font 1];
["Student",4.5,2.88,1,Left,Font 1];
["9. OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)",0.333,3.01,3,Left,Font 1];
["10. IS PATIENT'S CONDITION RELATED TO:",3.2,3.01,3,Left,Font 1];
["11. INSURED'S POLICY OR FECA NUMBER",5.2,3.01,3,Left,Font 1];
["a. OTHER INSURED'S POLICY OR GROUP NUMBER",0.333,3.36,3,Left,Font 1];
["a. EMPLOYMENT (CURRENT OR PREVIOUS)",3.2,3.36,3,Left,Font 1];
["a. INSURED'S DATE OF BIRTH",5.2,3.36,3,Left,Font 1];
["SEX",7.375,3.385,1,Left,Font 1];
["MM",5.625,3.44,1,Left,Font 1];
["DD",5.937,3.44,1,Left,Font 1];
["YY",6.25,3.44,1,Left,Font 1];
["YES",3.88,3.5,1,Left,Font 1];
["NO",4.5,3.5,1,Left,Font 1];
["M",6.906,3.5,1,Left,Font 1];
["F",7.625,3.5,1,Left,Font 1];
["b. OTHER INSURED'S DATE OF BIRTH",0.333,3.68,3,Left,Font 1];
["b. AUTO ACCIDENT?",3.2,3.68,1,Left,Font 1];
["PLACE (State)",4.6,3.68,1,Left,Font 1];
["b. EMPLOYER'S NAME OR SCHOOL NAME",5.2,3.68,3,Left,Font 1];
["SEX",2.26,3.707,1,Left,Font 1];
["MM",0.406,3.76,1,Left,Font 1];
["DD",0.75,3.76,1,Left,Font 1];
["YY",1.052,3.760,1.000,LEFT,Font 1];
["M",1.906,3.83,1,Left,Font 1];
["F",2.531,3.83,1,Left,Font 1];
["YES",3.88,3.83,1,Left,Font 1];
["NO",4.5,3.83,1,Left,Font 1];
["c. EMPLOYER'S NAME OR SCHOOL NAME",0.333,4.01,3,Left,Font 1];
["c. OTHER ACCIDENT?",3.2,4.01,1,Left,Font 1];
["c. INSURANCE PLAN NAME OR PROGRAM NAME",5.2,4.01,3,Left,Font 1];
["YES",3.88,4.17,1,Left,Font 1];
["NO",4.5,4.17,1,Left,Font 1];
["d. INSURANCE PLAN NAME OR PROGRAM NAME",0.333,4.35,3,Left,Font 1];
["10d. RESERVED FOR LOCAL USE",3.2,4.35,3,Left,Font 1];
["d. IS THERE ANOTHER HEALTH BENEFIT PLAN?",5.2,4.35,3,Left,Font 1];
["YES",5.625,4.525,1,Left,Font 1];
["NO",6.125,4.521,1.000,LEFT,Font 1];
["If yes, return to and complete item 9 a-d.",6.375,4.525,3,Left,Font 3];
["12.",0.333,4.68,1,Left,Font 1];
["READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM",0.469,4.677,4.563,CENTER,Font 2];
["PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE I authorize the release of any medical or other information necessary",0.469,4.760,6.000,LEFT,Font 1];
["to process this claim.  I also request payment of government benefits either to myself or to the party who accepts assignment",0.469,4.844,6.000,LEFT,Font 1];
["below.",0.469,4.927,1.000,LEFT,Font 1];
["13.",5.2,4.68,6,Left,Font 1]
["INSURED'S OR AUTHORIZED PERSON'S SIGNATURE.  I authorize",5.35,4.68,6,Left,Font 1]
["payment of medical benefits to the undersigned physician or supplier for",5.35,4.76,6,Left,Font 1]
["services described below.",5.35,4.84,1,Left,Font 1];
["SIGNED",0.469,5.225,1,Left,Font 1];
[{Box,0.8125,5.305,2.8,0,1,Black,Silver];
["DATE",3.687,5.225,1,Left,Font 1];
[{Box,3.937,5.305,1.187,0,1,Black,Silver];
["SIGNED",5.35,5.225,1,Left,Font 1];
[{Box,5.69,5.305,2.5,0,1,Black,Silver];
["14. DATE OF CURRENT:",0.333,5.35,3,Left,Font 1];
["ILLNESS (First symptom) OR",1.5,5.35,3,Left,Font 1];
["15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS",3.000,5.354,3.000,LEFT,Font 1];
["16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION",5.2,5.35,3,Left,Font 1];
["MM",0.406,5.43,1,Left,Font 1];
["DD",0.75,5.43,1,Left,Font 1];
["YY",1.05,5.43,1,Left,Font 1];
["INJURY (Accident) OR",1.500,5.427,3.000,LEFT,Font 1];
["GIVE FIRST DATE",3.13,5.43,3,Left,Font 1];

["MM",4,5.43,1,Left,Font 1];
["DD",4.35,5.43,1,Left,Font 1];
["YY",4.65,5.43,1,Left,Font 1];

["MM",5.625,5.43,1,Left,Font 1];
["DD",5.937,5.43,1,Left,Font 1];
["YY",6.25,5.43,1,Left,Font 1];

["MM",7.031,5.43,1,Left,Font 1];
["DD",7.344,5.43,1,Left,Font 1];
["YY",7.656,5.43,1,Left,Font 1];

["PREGNANCY (LMP)",1.5,5.51,1,Left,Font 1];
["FROM",5.25,5.55,1,Left,Font 1];
["TO",6.8,5.55,1,Left,Font 1];

["17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE",0.333,5.677,3.000,LEFT,Font 1];
["17a.",3.000,5.677,3.000,LEFT,Font 1];
["17b.  NPI",3.000,5.860,3,LEFT,Font 1];
["18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES",5.2,5.68,3,Left,Font 1];

["MM",5.625,5.76,1,Left,Font 1];
["DD",5.937,5.76,1,Left,Font 1];
["YY",6.25,5.76,1,Left,Font 1];

["MM",7.031,5.76,1,Left,Font 1];
["DD",7.344,5.76,1,Left,Font 1];
["YY",7.656,5.76,1,Left,Font 1];

["FROM",5.25,5.88,1,Left,Font 1];
["TO",6.8,5.88,1,Left,Font 1];

[{Box,2.979,5.333,0.000,0.667,1,Black,Silver}];

["19. RESERVED FOR LOCAL USE",0.333,6.010,3.000,LEFT,Font 1];
["20. OUTSIDE LAB?",5.2,6.01,3,Left,Font 1];
["$ CHARGES",7.188,6.010,3.000,LEFT,Font 1];

["YES",5.625,6.192,1,Left,Font 1];
["NO",6.125,6.192,1,Left,Font 1];

["21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY. (RELATE ITEMS 1,2,3 OR 4 TO ITEM 24E BY LINE)",0.333,6.354,4.125,LEFT,Font 1];
["22. MEDICAID RESUBMISSION",5.2,6.35,3,Left,Font 1];
["CODE",5.33,6.43,3,Left,Font 1];
["ORIGINAL REF. NO.",6.812,6.43,3,Left,Font 1];
["1. ",0.375,6.583,5.000,LEFT,Font 1];
[{Box,0.5,6.565,0,0.095,1,Black,Silver}];
[{Box,0.500,6.656,0.344,0.000,1,Black,Silver}];
[".",0.865,6.583,1.000,LEFT,Font 1];
[{Box,0.906,6.656,0.344,0.000,1,Black,Silver}];
["3. ",3.125,6.583,5.000,LEFT,Font 1];
[{Box,3.25,6.565,0,0.095,1,Black,Silver}];
[{Box,3.250,6.656,0.344,0.000,1,Black,Silver}];
[".",3.615,6.583,1.000,LEFT,Font 1];
[{Box,3.656,6.656,0.333,0.000,1,Black,Silver}];
["2. ",0.375,6.9,5,Left,Font 1];
[{Box,0.5,6.88,0,0.095,1,Black,Silver}];
[{Box,0.5,6.975,0.343,0,1,Black,Silver}];
[".",0.861,6.9,1,Left,Font 1];
[{Box,0.906,6.979,0.333,0.000,1,Black,Silver}];
["4. ",3.125,6.9,5,Left,Font 1];
[{Box,3.25,6.88,0,0.095,1,Black,Silver}];
[{Box,3.25,6.975,0.343,0,1,Black,Silver}];
[".",3.615,6.896,1.000,LEFT,Font 1];
[{Box,3.656,6.979,0.333,0.000,1,Black,Silver}];
["23. PRIOR AUTHORIZATION NUMBER",5.198,6.677,3.000,LEFT,Font 1];
["24.    A",0.333,7.01,1,Left,Font 1];
["B",2.219,7.01,1,Left,Font 1];
["C",2.5,7.01,1,Left,Font 1];
["D",3.5,7.01,1,Left,Font 1];
["E",4.900,7.010,1.000,LEFT,Font 1];
["F",5.594,7.01,1,Left,Font 1];
["G",6.19,7.01,1,Left,Font 1];
["H",6.5,7.01,1,Left,Font 1];
["I",6.781,7.01,1,Left,Font 1];
["J",7.063,7.010,1.000,CENTER,Font 1];

["24.    A",0.333,7.01,1,Left,Font 1];
["DATE(S) OF SERVICE",0.8125,7.12,2,Left,Font 5];
["Place",2.156,7.12,2,Left,Font 1];

["PROCEDURES, SERVICES, OR SUPPLIES",2.750,7.125,2.000,LEFT,Font 5];
["DAYS",6.152,7.12,2,Left,Font 5];
["EPSDT",6.406,7.12,2,Left,Font 5];

["DIAGNOSIS",4.700,7.135,1.000,LEFT,Font 1];
["RENDERING",7.406,7.135,1.000,LEFT,Font 1];
["POINTER",4.756,7.208,1.000,LEFT,Font 1];
["PROVIDER ID. #",7.375,7.219,1.000,LEFT,Font 1];

["From",0.656,7.19,1,Left,Font 5];
["To",1.594,7.19,1,Left,Font 5];
["of",2.208,7.188,1.000,LEFT,Font 5];

["(Explain Unusual Circumstances)",2.938,7.188,2.000,LEFT,Font 5];
["$ CHARGES",5.437,7.19,1,Left,Font 5];
["OR",6.1875,7.19,1,Left,Font 5];
["Family",6.41,7.19,1,Left,Font 5];
["ID.",6.740,7.135,1.000,LEFT,Font 1];
["QUAL.",6.698,7.219,1.00,LEFT,Font 1];


["MM",0.35,7.26,1,Left,Font 5];
["DD",0.7,7.26,1,Left,Font 5];
["YY",1,7.26,1,Left,Font 5];

["MM",1.281,7.26,1,Left,Font 5];
["DD",1.594,7.26,1,Left,Font 5];
["YY",1.906,7.26,1,Left,Font 5];

["Service",2.125,7.260,1.000,LEFT,Font 5];
["EMG",2.438,7.260,1.010,LEFT,Font 5];
["CPT/HCPCS",2.875,7.26,1,Left,Font 5];
["MODIFIER",3.688,7.260,1.000,LEFT,Font 5];
["UNITS",6.125,7.26,1,Left,Font 5];
["Plan",6.448,7.260,1.000,LEFT,Font 5];


["25. FEDERAL TAX I.D. NUMBER",0.333,9.354,2.000,LEFT,Font 1];
["SSN",1.906,9.35,1,Left,Font 1];
["EIN",2.156,9.354,1.000,LEFT,Font 1];
["26. PATIENT'S ACCOUNT NUMBER",2.55,9.35,2,Left,Font 1];
["27. ACCEPT ASSIGNMENT?",4.052,9.354,2.000,LEFT,Font 1];
["(For govt. claims, see back)",4.052,9.427,2.000,LEFT,Font 5];
["28. TOTAL CHARGE",5.219,9.35,2,Left,Font 1];
["29. AMOUNT PAID",6.344,9.354,2.000,LEFT,Font 1];
["30. BALANCE DUE",7.312,9.35,2,Left,Font 1];
["YES",4.219,9.542,2.000,LEFT,Font 1];
["NO",4.729,9.542,2.000,LEFT,Font 1];
["$",5.2500,9.542,0.500,LEFT,Font 1];
["$",6.470,9.542,0.500,LEFT,Font 1];
["$",7.292,9.542,0.500,LEFT,Font 1];

["31. SIGNATURE OF PHYSICIAN OR SUPPIER",0.333,9.68,3,Left,Font 5];
["32. SERVICE FACILITY LOCATION INFORMATION",2.552,9.677,3.000,LEFT,Font 5];
["33. BILLING PROVIDER INFO & PH #",5.219,9.677,3.000,LEFT,Font 5];
["      INCLUDING DEGREES OR CREDENTIALS",0.333,9.760,3.000,LEFT,Font 5];
["(I certify that the statements on the reverse",0.469,9.844,3.000,LEFT,Font 5];
["apply to this bill and are made a part thereof.)",0.458,9.917,3.000,LEFT,Font 5];


["SIGNED",0.333,10.396,3.000,LEFT,Font 5];
["DATE",1.875,10.4,3,Left,Font 5];
["a.",2.519,10.396,3.000,LEFT,Font 5];
["b.",3.740,10.396,3.000,LEFT,Font 5];
["a.",5.219,10.396,3.000,LEFT,Font 5];
["b.",6.344,10.4,3,Left,Font 5];



[{Box,2.469,10.344,5.750,0.156,1,Black,Silver}]
[{Box,3.635,10.344,2.677,0.146,1,Black,Silver}]
[{Box,7.219,9.333,1.000,0.333,1,Black,Silver}]
[{Box,2.979,5.844,2.188,0.156,1,Black,Silver}]
[{Box,3.188,5.667,0.198,0.333,1,Black,Silver}]
[END INSURANCE FORM]