Date: <ChargeCapture.Date>

Performing Provider
<ChargeCapture.Provider.Name>
<ChargeCapture.Provider.Address>
<ChargeCapture.Provider.City> 
<ChargeCapture.Provider.State> <ChargeCapture.Provider.Zip>

Place of Service
<ChargeCapture.ProcLocation.Name>	Patient
<PersonalInfo.FirstName>  <PersonalInfo.LastName>
<PresentAddress.Address> <PresentAddress.Apt#>
<PresentAddress.City> <PresentAddress.State> <PresentAddress.Zip>
<PresentAddress.CellPhone>
<PersonalInfo.EmailAddress>

Date of Birth: <PersonalInfo.DOB>	

Insurance Information				

	Primary	Secondary	
Company	<PrimaryInsurance.InsuranceCompany>	<SecondaryInsurance.InsuranceCompany>	
Policy ID	<PrimaryInsurance.PolicyNumber>	<SecondaryInsurance.PolicyNumber>	
Insured	<PrimaryInsurance.Insured>	<SecondaryInsurance.Insured>	
Group Number	<PrimaryInsurance.GroupNumber>	<SecondaryInsurance.GroupNumber>	
Claims Address	<PrimaryInsurance.ClaimsAddress>
<PrimaryInsurance.City>  <PrimaryInsurance.State>  
<PrimaryInsurance.Zip>	<SecondaryInsurance.ClaimsAddress>
<SecondaryInsurance.City>  <SecondaryInsurance.State>  
<SecondaryInsurance.Zip>	
Phone	<PrimaryInsurance.Phone>	<SecondaryInsurance.Phone>	

CPT and Diagnoses Codes 				

CPT Codes:	<ChargeCapture.PItem.ProcCode> <ChargeCapture.Pitem.Modifiers.Modifier1> - <ChargeCapture.Pitem.Description>
<ChargeCapture.PItem.ProcCode> <ChargeCapture.Pitem.Modifiers.Modifier1> - <ChargeCapture.Pitem.Description>
<ChargeCapture.PItem.ProcCode> <ChargeCapture.Pitem.Modifiers.Modifier1> - <ChargeCapture.Pitem.Description>
<ChargeCapture.PItem.ProcCode> <ChargeCapture.Pitem.Modifiers.Modifier1> - <ChargeCapture.Pitem.Description>

Diagnoses:	<Invoice.Diag.Code1> <Invoice.Diag.Code2> <Invoice.Diag.Code3> <Invoice.Diag.Code4>
<Invoice.Diag.Code5> <Invoice.Diag.Code6> <Invoice.Diag.Code7> <Invoice.Diag.Code8>    	

					

Version 20190402