[FORM OPTIONS] MAXLINES = 6 LINEHEIGHT=0.1667 LEFTOFFSET=-2 UPPERCASE CPI=10 FILE=ALTA1.CLM [END FORM OPTIONS] [MARGINS] Top = 0.0 Left = 0.0 Right = 0.0 Bottom = 0.0 [END MARGINS] [FONTS] Font 1 = Courier New, 10, Normal [END FONTS] [PATIENT INFORMATION] [Primary:Company,5.000,0.000,4.000,LEFT,Font 1]; [Primary:Address1,5,,4,Left,Font 1]; [Primary:Address2,5,,4,Left,Font 1]; [Primary:City + ", " + Primary:State + " " + Primary:Zip,5,,4,Left,Font 1]; ; ; [IF Bill:Ins2_Type = "0"] ["X",0.333,0.000,1.000,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_Type = "1"] ["X",1,,1.2,Left,Font 1] [ENDIF] [IF Bill:Ins1_Type = "2"] ["X",1.72,,1,Left,Font 1] [ENDIF] [IF Bill:Ins1_Type = "3"] ["X",2.625,0.000,1.000,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_Type = "4"] ["X",3.32,,1,Left,Font 1] [ENDIF] [IF Bill:Ins1_Type = "5"] ["X",4.125,,1,Left,Font 1] [ENDIF] [IF Bill:Ins1_Type = "6"] ["X",4.75,,1,Left,Font 1] [ENDIF] [Bill:Ins1_ID,5.25,,3,Left,Font 1] ; ; [Patient:LastName + ", " + Patient:FirstName + " " + Patient:Middle,0.333,0.000,2.750,LEFT,Font 1] [Month(Patient:BirthDate),3.250,0.000,1.000,LEFT,Font 1] [Day(Patient:BirthDate),3.458,0.000,1.000,LEFT,Font 1] [YY(Patient:BirthDate),3.771,0.000,1.000,LEFT,Font 1] [IF Patient:Sex = "M"] ["X",4.458,0.000,1.010,LEFT,Font 1] [ENDIF] [IF Patient:Sex = "F"] ["X",4.865,0.000,1.000,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_type <> "0"] [Guarantor1:LastName + ", " + Guarantor1:FirstName + " " + Guarantor1:Middle,5.250,1.833,3.000,LEFT,Font 1] [ENDIF] ; ; [Patient:Address1,0.333,2.167,2.75,Left, Font 1] [IF Bill:Ins1_GRel = "M"] ["X",3.53,,1,Left,Font 1] [ENDIF] [IF Bill:Ins1_GRel = "S"] ["X",4.03,,1,Left,Font 1] [ENDIF] [IF Bill:Ins1_GRel = "P"] ["X",4.46,,1,Left,Font 1] [ENDIF] [IF Bill:Ins1_GRel = "O"] ["X",4.96,,1,Left,Font 1] [ENDIF] [IF Bill:Ins1_Type <> "0"] [Guarantor1:Address1,5.250,0.000,2.750,LEFT,Font 1] [ENDIF] ; ; [Patient:City,0.323,2.479,2.500,LEFT,Font 1] [Patient:State,2.875,0.000,1.000,LEFT,Font 1] [IF Patient:Status = "S"] ["X",3.72,,1,Left,Font 1] [ENDIF] [IF Patient:Status = "M"] ["X",4.35,,1,Left,Font 1] [ENDIF] [IF Patient:Status = "D"] ["X",4.95,,1,Left,Font 1] [ENDIF] [IF Patient:Status = "W"] ["X",4.95,,1,Left,Font 1] [ENDIF] [IF Patient:Status = ""] ["X",4.95,,1,Left,Font 1] [ENDIF] [IF Bill:Ins1_Type <> "0"] [Guarantor1:City,5.250,0.000,3.000,LEFT,Font 1] [Guarantor1:State,7.5,,1,Left, Font 1] [ENDIF] ; ; [Patient:Zip,0.333,0.000,2.500,LEFT,Font 1] [Patient:Phone_Home,1.625,0.000,2.500,LEFT,Font 1] [IF Patient:Employer <> ""] ["X",3.72,,1,Left,Font 1] [ENDIF] [IF Patient:School <> ""] [IF Patient:Full_Time = True] ["X",4.35,,1,Left,Font 1] [ELSE] ["X",4.95,,1,Left,Font 1] [ENDIF] [ENDIF] [IF Bill:Ins1_Type <> "0"] [Guarantor1:Zip,5.25,,2.5,Left, Font 1] [Guarantor1:Phone_Home,6.656,,2.5,Left, Font 1] [ENDIF] ; ; [IF Bill:Ins1_Type = "0"] [IF BILL:INS2_NAME = "MEDIGAP"] [IF BILL:INS2_GREL = "M"] ["SAME",0.333,3.167,2.500,LEFT,Font 1] [ELSE] [Guarantor2:LastName + " " + Guarantor2:FirstName + " " + Guarantor2:Middle,0.333,3.167,2.500,LEFT,Font 1] [ENDIF] [ENDIF] [ENDIF] [IF Bill:Ins1_Type <> "0"] [Bill:Ins1_Group,5.250,0.000,3.000,LEFT,Font 1] [ELSE] ["NONE",5.250,0.000,3.000,LEFT,Font 1] [ENDIF] ; ; [IF Bill:Ins1_Type <> "0"] [IF Bill:Ins2_Code <> ""] [Bill:Ins2_ID,0.333,0.000,3.000,LEFT,Font 1] [ENDIF] [ENDIF] [IF Bill:Acc_Type = "E"] ["X",3.72,,1,Left,Font 1] [ELSE] ["X",4.35,,1,Left,Font 1] [ENDIF] [IF Bill:Ins1_Type <> "0"] [Month(Guarantor1:BirthDate),5.625,0.000,1.000,LEFT,Font 1] [Day(Guarantor1:BirthDate),5.937,,1,Left,Font 1] [YY(Guarantor1:BirthDate),6.25,,1,Left,Font 1] [IF Guarantor1:Sex = "M"] ["X",7.062,,1,Left,Font 1] [ENDIF] [IF Guarantor1:Sex = "F"] ["X",7.65,,1,Left,Font 1] [ENDIF] [ENDIF] ; ; [IF Bill:Ins1_Type <> "0"] [Month(Guarantor2:BirthDate),0.271,0.000,1.000,LEFT,Font 1] [Day(Guarantor2:BirthDate),0.588,,1,Left,Font 1] [YY(Guarantor2:BirthDate),0.9,,1,Left,Font 1] [IF Guarantor2:Sex = "M"] ["X",2.02,,1,Left,Font 1] [ENDIF] [IF Guarantor2:Sex = "F"] ["X",2.556,,1,Left,Font 1] [ENDIF] [ENDIF] [IF Bill:Acc_Type = "A"] ["X",3.72,,1,Left,Font 1] [Bill:Acc_State,4.75,,1,Left,Font 1] [ELSE] ["X",4.35,,1,2,Left,Font 1] [ENDIF] [IF Bill:Ins1_Type <> "0"] [IF Guarantor1:Employer <> ""] [Employer1:Company,5.250,0.000,2.500,LEFT,Font 1] [ENDIF] [ENDIF] ; ; [IF Bill:Ins1_Type = "0"] [IF BILL:INS2_NAME = "MEDIGAP"] [IF secondary:OCNA = " "] [secondary:address1 + " " + secondary:city + " " + secondary:state,0.333,0.000,2.500,LEFT,Font 1] [ELSE] [" ",0.333,0.000,2.500,Left,Font 1] [ENDIF] [ENDIF] [ENDIF] [IF Bill:Acc_Type = "O"] ["X",3.72,,1,Left,Font 1] [ELSE] ["X",4.35,,1,Left,Font 1] [ENDIF] [IF Bill:Ins1_Type <> "0"] [if bill:ins1_name = ""] [Primary:Company,5.250,0.000,3.000,LEFT,Font 1] [ELSE] [Bill:Ins1_Name,5.250,0.000,3.000,LEFT,Font 1] [ENDIF] [ENDIF] ; ; [Bill:Local,3.2,,2,Left,Font 1] [IF Bill:Ins1_Type <> "0"] [IF Bill:Ins2_Code <> ""] [Secondary:Company,0.333,0.000,2.500,LEFT,Font 1] ["X",5.406,0.000,1.000,LEFT,Font 1] [ELSE] ["X",5.938,0.000,1.000,LEFT,Font 1] [ENDIF] [ENDIF] ; ; ; [IF Patient:Sig_Info = True] ["Signature on file",1.000,0.000,2.500,LEFT,Font 1] [{Today},4.000,0.000,1.000,LEFT,Font 1] [ENDIF] [IF Patient:Sig_Assign = True] ["Signature on file",6.000,0.000,2.500,LEFT,Font 1] [ENDIF] ; ; ; [Month(Bill:Sympt_Date),0.375,,1,Left,Font 1] [Day(Bill:Sympt_Date),0.688,,1,Left,Font 1] [YY(Bill:Sympt_Date),1,,1,Left,Font 1] [Month(Bill:Similar),3.969,,1,Left,Font 1] [Day(Bill:Similar),4.32,,1,Left,Font 1] [YY(Bill:Similar),4.635,0.000,1.000,LEFT,Font 1] [Month(Bill:Work1),5.625,0.000,1.000,LEFT,Font 1] [Day(Bill:Work1),5.937,,1,Left,Font 1] [YY(Bill:Work1),6.240,0.000,1.000,LEFT,Font 1] [Month(Bill:Work2),7.031,0.000,1.000,LEFT,Font 1] [Day(Bill:Work2),7.354,0.000,1.000,LEFT,Font 1] [YY(Bill:Work2),7.635,0.000,1.000,LEFT,Font 1]; [IF referral:ref_upin <> ""] ["1G " + referral:ref_upin,3.221,0.000,2.500,LEFT,Font 1]; [ELSE] ; [ENDIF] [Referral:TITLE,0.333,,2.500,LEFT,Font 1] [" "+Referral:NPI,3.219,0.000,2.500,LEFT,Font 1] [Month(Bill:Hosp1),5.625,,1,Left,Font 1] [Day(Bill:Hosp1),5.937,,1,Left,Font 1] [YY(Bill:Hosp1),6.24,,1,Left,Font 1] [Month(Bill:Hosp2),7.03,,1,Left,Font 1] [Day(Bill:Hosp2),7.344,,1,Left,Font 1] [YY(Bill:Hosp2),7.615,0.000,1.000,LEFT,Font 1] ; ; [Bill:Local1,0.333,0.000,4.800,LEFT,Font 1] [IF Bill:Lab <> 0] ["X",5.437,,1,Left,Font 1] [Bill:Lab,7,,1,Left,Font 1] [ELSE] ["X",5.868,,1,Left,Font 1] [ENDIF] ; ; [Bill:Diag1,0.48,,1,Left,Font 1] [Bill:Diag3,3.23,,1,Left,Font 1] [Bill:Medicaid,5.25,,1,Left,Font 1] [Bill:Med_Ref,6.8,,1,Left,Font 1] ; ; [Bill:Diag2,0.479,0.000,1.000,LEFT,Font 1] [Bill:Diag4,3.23,,1,Left,Font 1] [Bill:Ins1_Prior,5.250,0.000,3.000,LEFT,Font 1] ; ; ; [END PATIENT INFORMATION] [SERVICE DETAIL] [IF insuranceid:prov_id <> ""] [IF Bill:Ins1_Type = "0"] ["1C",6.670,,1,Left,Font 6] [ENDIF] [IF Bill:Ins1_Type = "1"] ["1D",6.670,,1.2,Left,Font 6] [ENDIF] [IF Bill:Ins1_Type = "2"] ["1H",6.670,,1.000,LEFT,Font 6] [ENDIF] [IF Bill:Ins1_Type = "3"] ["1G",6.670,,1,Left,Font 6] [ENDIF] [IF Bill:Ins1_Type = "4"] ["G2",6.670,,1,Left,Font 6] [ENDIF] [IF Bill:Ins1_Type = "5"] ["G2",6.670,,1,Left,Font 6] [ENDIF] [IF Bill:Ins1_Type = "6"] ["G2",6.670,,1,Left,Font 6] [ENDIF] [IF Bill:Ins1_Type = "7"] ["1B",6.670,,1,Left,Font 6] [ENDIF] [IF Bill:Ins1_Type = "8"] ["X5",6.670,,1,Left,Font 6] [ENDIF] [ENDIF] [insuranceid:prov_id,7.000,0.000,3.000,LEFT,Font 1]; [Month(Detail:Date) + Day(Detail:Date) + Year(Detail:Date),0.354,0.000,1.000,LEFT,Font 1] [Month(Detail:End_Date) + Day(Detail:End_Date) + Year(Detail:End_Date),1.250,0.000,1.000,LEFT,Font 1] [Detail:Med_POS,2.125,0.000,1.000,LEFT,Font 1] [Detail:EMG,2.5,0.000,1.000,LEFT,Font 1] [Fee:CPT_Code,2.802,0.000,1.000,LEFT,Font 1] [Detail:Mod1,3.5,,1,Left,Font 1] [Detail:Mod2,3.8,,1,Left,Font 1] [Detail:Mod3,4.1,,1,Left,Font 1] [Detail:Mod4,4.4,,1,Left,Font 1] [Detail:Diag,4.72,,1,Left, Font 1] [Cents(Detail:Extended),5.5,,0.5,Right,Font 1] [Dollars(Detail:Extended),5.198,0.000,0.500,RIGHT,Font 1] [Dollars(Detail:Units),6.063,0.000,0.302,RIGHT,Font 1] [employee:npi,7.000,0.000,3.000,LEFT,Font 1]; [END SERVICE DETAIL] [CLAIM TOTAL] ; [IF Employee:Tax_ID <> ""] [Employee:Tax_ID,0.333,,1.5,Left, Font 1] ["X",2.1875,,1,Left, Font 1] [ELSE] [Employee:SS,0.333,,1.5,Left, Font 1] ["X",1.906,0.000,1.000,LEFT,Font 1] [ENDIF] [Patient:Code,2.52,,1.25,Left, Font 1] [IF BILL:INS1_ASSGN = True] ["X",4.031,0.000,1.000,LEFT,Font 1] [ELSE] ["X",4.531,0.000,1.000,LEFT,Font 1] [ENDIF] [Dollars({Charges}),5.3125,,0.625,Right,Font 1] [Cents({Charges}),6.000,0.000,0.250,LEFT,Font 1] [Dollars({Payments}),6.4375,,0.5,Right,Font 1] [Cents({Payments}),7,,0.25,Left,Font 1] [Dollars({Balance}),7.275,,0.5,Right,Font 1] [Cents({Balance}),7.95,,0.25,Left,Font 1] ; [Practice:Phone,5.698,0.000,2.115,LEFT,Font 1]; [IF Bill:facility = ""] [Practice:Name,2.6,,2.5,Left,Font 1] [ELSE] [Facility:Company,2.6,,2.5,Left,Font 1] [ENDIF] [Practice:Name,5.323,0.000,2.500,LEFT,Font 1]; [IF Bill:facility = ""] [Practice:Address1,2.6,,2.5,Left,Font 1] [ELSE] [Facility:Address1,2.604,0.000,2.500,LEFT,Font 1] [ENDIF] [Practice:Address1,5.313,,2.500,LEFT,Font 1]; [Employee:Title,0.354,0.000,2.083,LEFT,Font 1] [IF Bill:facility = ""] [Practice:City + " " +Practice:State + " " + Practice:Zip ,2.6,,2.5,Left,Font 1] [ELSE] [Facility:City + " " +Facility:State + " " + Facility:Zip,2.604,0.000,2.500,LEFT,Font 1] [ENDIF] [Practice:City + " " +Practice:State + " " + Practice:Zip,5.323,0.000,2.500,LEFT,Font 1]; [{Today},1.000,0.000,1.438,LEFT,Font 1] [IF bill:facility = ""] [employee:npi,2.604,0.000,1.073,LEFT,Font 1] [IF insuranceid:prov_id <> ""] [IF Bill:Ins1_Type = "0"] ["1C",3.719,0.000,1.000,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_Type = "1"] ["1D",3.719,0.000,0.500,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_Type = "2"] ["1H",3.719,0.000,0.500,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_Type = "3"] ["1G",3.708,0.000,0.500,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_Type = "4"] ["G2",3.719,0.000,0.500,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_Type = "5"] ["G2",3.719,0.000,0.500,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_Type = "6"] ["G2",3.729,0.000,0.500,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_Type = "7"] ["1B",3.719,0.000,0.500,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_Type = "8"] ["X5",3.740,0.000,0.500,LEFT,Font 1] [ENDIF] [InsuranceID:prov_id,3.990,0.000,2.677,LEFT,Font 1] [ENDIF] [ELSE] [facility:NPI,2.604,0.000,1.052,LEFT,Font 1] [facility:facility,3.979,0.000,2.500,LEFT,Font 1] [ENDIF] [IF Practice:Usreclaim3 <> ""] [Practice:Usreclaim3,5.313,0.000,1.115,LEFT,Font 1] [ELSE] [employee:NPI,5.313,0.000,1.115,LEFT,Font 1] [ENDIF] [IF Primary:Groupid <> ""] [IF Bill:Ins1_Type = "0"] ["1C",6.719,0.000,0.510,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_Type = "1"] ["1D",6.719,0.000,0.500,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_Type = "2"] ["1H",6.719,0.000,0.500,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_Type = "3"] ["1G",6.719,0.000,0.500,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_Type = "4"] ["G2",6.719,0.000,0.500,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_Type = "5"] ["G2",6.719,0.000,0.500,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_Type = "6"] ["G2",6.708,0.000,0.500,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_Type = "7"] ["1B",6.719,0.000,0.500,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_Type = "8"] ["X5",6.719,0.000,0.500,LEFT,Font 1] [ENDIF] [Primary:Groupid,7.000,0.000,2.677,LEFT,Font 1] [ELSE] [IF insuranceid:prov_id <> ""] [IF Bill:Ins1_Type = "0"] ["1C",6.600,0.000,0.510,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_Type = "1"] ["1D",6.600,0.000,0.500,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_Type = "2"] ["1H",6.600,0.000,0.500,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_Type = "3"] ["1G",6.600,0.000,0.500,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_Type = "4"] ["G2",6.600,0.000,0.500,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_Type = "5"] ["G2",6.600,0.000,0.500,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_Type = "6"] ["G2",6.600,0.000,0.500,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_Type = "7"] ["1B",6.600,0.000,0.500,LEFT,Font 1] [ENDIF] [IF Bill:Ins1_Type = "8"] ["X5",6.600,0.000,0.500,LEFT,Font 1] [ENDIF] [InsuranceID:prov_id,6.800,0.000,2.677,LEFT,Font 1] [ENDIF] [ENDIF] ; [END CLAIM TOTAL] [INSURANCE FORM] [END INSURANCE FORM]