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| Code Block |
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FirstName - first_name LastName - last_name DOB - dob Gender - gender Address - street_addr City - city State - state ZipCode - zip // Primary Insurance Fields Insurance - insurance.carrierinsurer_codeid (e.g. car7147 - AMD code) Insurance Coverage - insurance.respparty (e.g self, child, spouse, other) Group Number - insurance.group_number Subscriber Number - insurance.subscriber_num // Secondary Insurance Fields (Optional) Secondary Insurance - insurance.secondary_insurer_carrierid (e.g. car7147 - AMD code) Secondary Group Number - insurance.secondary_group_number Secondary Subscriber Number - insurance.secondary_subscriber_num Insurance Card Front - insurance.card_front Insurance Card Back - insurance.card_back If dependent (child, spouse, other): Guarantor Name - insurance.guarantor_name Guarantor DOB - insurance.guarantor_dob Guarantor Address1 - insurance.guarantor_address Guarantor City - insurance.guarantor_city Guarantor State - insurance.guarantor_state Guarantor Zip - - insurance.guarantor_zip |
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