Patient Number                                                13Insurance Form, Primary                                       11Print Status, Primary                                         10Insurance Form Type, Secondary                                11Print Status, Secondary                                       10Estimate or Actual                                            10Do you want to suppress SIGNATURE ON FILE?                    00Are x-rays being sent?                                        00Is treatment result of occupational illness or injury?        00Is treatment result of auto accident?                         00Is treatment result of other accident?                        00Are any services covered by another plan?                     00Is treatment for orthodontics?                                00Was laboratory work performed outside office?                 00Has patient ever had same or similar symptoms?                00Is this an emergency?                                         00yn4?                                                          00yn5?                                                          00yn6?                                                          00yn7?                                                          00yn8?                                                          00yn9?                                                          00yn10?                                                         00yn11?                                                         00yn12?                                                         00yn13?                                                         00yn14?                                                         00yn15?                                                         00yn16?                                                         00yn17?                                                         00yn18?                                                         00yn19?                                                         00Is treatment the result of EPSDT screening?                   10Is patient covered by a Medical Plan?                         10Is patient a full-time student?                               10*RESERVED - Do Not Use                                        10*RESERVED - Do Not Use                                        10*RESERVED - Do Not Use                                        10Black Hole #1                                                 11Black Hole #2                                                 11Black Hole #3                                                 11Black Hole #4                                                 11Date that treatment began?                                    12Date appliances placed?                                       02Date of prior placement?                                      02Date of Illness or injury?                                    02Date able to return to work?                                  02Date of total disability (ending)?                            02Date of partial disability (beginning)?                       02Date of partial disability (ending)?                          02Give hospitalization date (beginning)?                        02Give hospitalization date (ending)?                           02Date of total disability (beginning)?                         02Date first consulted?                                         02Date of service (beginning)?                                  02date5?                                                        02date6?                                                        02date7?                                                        02Date of service (ending)?                                     02date8?                                                        02date9?                                                        02*RESERVED - Do Not Use                                        12*RESERVED - Do Not Use                                        12fitb1?                                                        03fitb2?                                                        03fitb7?                                                        03fitb9?                                                        03fitb12?                                                       03fitb16?                                                       03fitb19?                                                       03Prior Benefit Authorization Type?                             13Referring Physician ID?                                       13Pre-Determination Number Type?                                13Insured ID #?                                                 03fitb6?                                                        03fitb13?                                                       03fitb14?                                                       03fitb15?                                                       03Description of other accident?                                03Description of occupational illness or injury?                03Description of automobile accident?                           03Reason for replacement of prosthesis?                         03Brief description of other plan?                              03fitb18?                                                       03Diagnosis Codes and Coding Method?                            13Pre-Determination Number?                                     13If full-time student:  School Name, City, State?              13fitb4?                                                        03fitb5?                                                        03Remarks?                                                      03fitb10?                                                       03fitb11?                                                       03fitb17?                                                       03Remarks?                                                      13Remarks?                                                      13Remarks?                                                      13Diagnosis #1?                                                 03Diagnosis #2?                                                 03Diagnosis #3?                                                 03Diagnosis #4?                                                 03Name/add. service performd?                                   03dollar1?                                                      04dollar2?                                                      04dollar3?                                                      04*RESERVED - Do Not Use                                        14Number of X-Rays?                                             01Treatment months remaining?                                   01number?                                                       01*RESERVED - Do Not Use                                        11Place of service?                                             15Time of service?                                              15If prosthesis, is this the initial placement?                 15mc1?                                                          05mc2?                                                          05*RESERVED - Do Not Use (MC #6)                                15*RESERVED - Do Not Use                                        15*RESERVED - Do Not Use                                        15*RESERVED - Do Not Use                                        15