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Jun 19th, 2019
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  1. <HTML>
  2.  
  3. <TABLE CELLSPACING=0 CELLPADDING=0 BORDER=1 RULES=ALL COLS=66 ROWS=4210>
  4.  
  5. <TR>
  6.  
  7. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=65><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">DATE</FONT> </TH>
  8.  
  9. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=65><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">PT ID</FONT> </TH>
  10.  
  11. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=65><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">MR NUM</FONT> </TH>
  12.  
  13. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=161><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">PATIENT NAME</FONT> </TH>
  14.  
  15. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=142><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">NAME</FONT> </TH>
  16.  
  17. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=95><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">LAST NAME</FONT> </TH>
  18.  
  19. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=100><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">FIRST NAME</FONT> </TH>
  20.  
  21. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=101><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">MIDDLE INITIAL</FONT> </TH>
  22.  
  23. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=220><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">ADDRESS</FONT> </TH>
  24.  
  25. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=166><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">STREET1</FONT> </TH>
  26.  
  27. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=174><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">STREET2</FONT> </TH>
  28.  
  29. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=53><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">ZIP</FONT> </TH>
  30.  
  31. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=82><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">PHONE</FONT> </TH>
  32.  
  33. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=103><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">CELL PHONE</FONT> </TH>
  34.  
  35. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=74><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">FAX</FONT> </TH>
  36.  
  37. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=188><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">EMAIL</FONT> </TH>
  38.  
  39. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=151><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">EMERG NAME</FONT> </TH>
  40.  
  41. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=126><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">EMERGENCY PH</FONT> </TH>
  42.  
  43. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=73><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">DOB</FONT> </TH>
  44.  
  45. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=41><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">SEX</FONT> </TH>
  46.  
  47. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=69><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">MARITAL</FONT> </TH>
  48.  
  49. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=89><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">SSN</FONT> </TH>
  50.  
  51. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=65><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">REF</FONT> </TH>
  52.  
  53. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=65><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">PCP</FONT> </TH>
  54.  
  55. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=65><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">STP</FONT> </TH>
  56.  
  57. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=65><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">PRI</FONT> </TH>
  58.  
  59. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=65><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">SEC</FONT> </TH>
  60.  
  61. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">REPORT</FONT> </TH>
  62.  
  63. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">TREAT PROV</FONT> </TH>
  64.  
  65. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">RACE</FONT> </TH>
  66.  
  67. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">ETHNIC</FONT> </TH>
  68.  
  69. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">LANGUAGE</FONT> </TH>
  70.  
  71. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">REFERRING</FONT> </TH>
  72.  
  73. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">OCCUPATION</FONT> </TH>
  74.  
  75. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">CT CODE</FONT> </TH>
  76.  
  77. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">GUARANTOR</FONT> </TH>
  78.  
  79. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">EMPLOYER</FONT> </TH>
  80.  
  81. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">INS SEQ</FONT> </TH>
  82.  
  83. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">IC CODE</FONT> </TH>
  84.  
  85. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">INS SUBSCRIBER</FONT> </TH>
  86.  
  87. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">INS GROUP</FONT> </TH>
  88.  
  89. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">INS PLAN</FONT> </TH>
  90.  
  91. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">INS FROM</FONT> </TH>
  92.  
  93. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">INS TO</FONT> </TH>
  94.  
  95. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">INS CO PAY</FONT> </TH>
  96.  
  97. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">INS DEDUCTIBLE</FONT> </TH>
  98.  
  99. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">INS STATUS</FONT> </TH>
  100.  
  101. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">INS PRIMARY</FONT> </TH>
  102.  
  103. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">INS ADJUSTER</FONT> </TH>
  104.  
  105. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">INS ASSIGNMENT</FONT> </TH>
  106.  
  107. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">INS CLAIM</FONT> </TH>
  108.  
  109. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">INS RELATION</FONT> </TH>
  110.  
  111. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">CLINIC</FONT> </TH>
  112.  
  113. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">ACCOUNT</FONT> </TH>
  114.  
  115. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">IMM PROTECT DATE</FONT> </TH>
  116.  
  117. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">TRANSMIT PERMISSION</FONT> </TH>
  118.  
  119. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=0><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">SUFFIX</FONT> </TH>
  120.  
  121. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=97><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">DATE CREATED</FONT> </TH>
  122.  
  123. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=97><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">CREATED BY</FONT> </TH>
  124.  
  125. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=97><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">DATE MODIFIED</FONT> </TH>
  126.  
  127. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=97><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">MODIFIED BY</FONT> </TH>
  128.  
  129. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=97><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">DATE DELETED</FONT> </TH>
  130.  
  131. <TH ALIGN=LEFT VALIGN=CENTER BGCOLOR="#FFFFFF" HEIGHT=18 WIDTH=97><FONT SIZE=1 COLOR="#000000" FACE="MS Sans Serif">DELETED BY</FONT> </TH>
  132.  
  133. </TR>
  134.  
  135. <TR>
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