LINES 1-16
WHAT LINE WOULD YOU LOCATE THE FACILITY NAME, STREET ADDRESS, CITY, STATE, ZIP, TELEPHONE, FAX, AND COUNTRY CODE?
FORM LOCATOR 1
NOT IN USE
FORM LOCATOR 30
REVENUE CODES FROM NUBC MANUAL
FORM LOCATOR 42
PAYER IDENTIFICATION (PRIMARY, SECONDARY, TERTIARY) INFORMATION
FORM LOCATOR 50
ADMITTING DX CODE
FORM LOCATOR 69
PAY-TO-NAME "BILLING COMPANY"
FORM LOCATOR 2
ACCIDENT STATE
FORM LOCATOR 29
RESPONSIBLE PARTY ADDRESS
FORM LOCATOR 38
BILLING PROVIDER NPI
FORM LOCATOR 56
ATTENDING PROVIDER NPI, ID QUALIFIERS, LAST AND FIRST NAME
FORM LOCATOR 76
MEDICAL RECORD NUMBER AKA "MRN"
FORM LOCATOR 3B
CONDITION CODES USING TWO-DIGIT ALPHA NUMERCA CODES FROM NUBC MANUAL UP TO 11 OCCURRENCES
FORM LOCATOR 18-28
SERVICE DATES
FORM LOCATOR 45
OTHER PROVIDER ID (PRIMARY, SECONDARY, TERTIARY)
FORM LOCATOR 57
PATIENT REASON FOR VISIT CODES
FORM LOCATOR 70
TYPE OF BILL "TOB"
FORM LOCATOR 4
DISCHARGE HOUR "DHR"
FORM LOCATOR 16
NON-COVERED CHARGES
FORM LOCATOR 47
PRINCIPLE DX
FORM LOCATOR 67
EXTERNAL CAUSE OF INJURY CODE AND POA INDICATOR
FORM LOCATOR 72
FEDERAL TAX NUMBER FOR "YOUR" FACILITY
FORM LOCATOR 5
DISCHARGE STATUS USIND TWO-DIGIT CODE FROM THE NUBC MANUAL
FORM LOCATOR 17
TOTAL CHARGES
FORM LOCATOR 47
TREATMENT AUTHORIZATION CODE
FORM LOCATOR 63
BILLING REMARKS