| Prompt |
Response |
Req |
Len |
| Employer Code |
Type the code you want or click the magnifying glass to search the table. |
 |
8 |
| Employer Name |
This field is informational only and reflects the employer's name as it is stored in the Employer Code Table. |
|
40 |
| Address Line One |
This field is informational only and reflects the employer's address as it is stored in the Employer Code Table. |
|
40 |
| Address Line Two |
This field is informational only and reflects any additional address information for the employer as it is stored in the Employer Code Table. |
|
40 |
| City |
This field is informational only and reflects the employer's city as it is stored in the Employer Code Table. |
|
30 |
| State |
This field is informational only and reflects the employer's state as it is stored in the Employer Code Table. |
|
3 |
| Zip Code |
This field is informational only and reflects the employer's zip code as it is stored in the Employer Code Table. |
|
10 |
| Contact Name |
This field is informational only and reflects the contact name for the employer as it is stored in the Employer Code Table. |
|
30 |
| Contact Phone |
This field is informational only and reflects the phone number for the contact person for the employer as it is stored in the Employer Code Table. |
|
20 |
| Contact Fax |
This field is informational only and reflects the fax number for the contact person for the employer as it is stored in the Employer Code Table. |
|
20 |
| Employee Phone |
Type the employee's work telephone number and extension. |
|
20 |
| Employee Fax |
Type the employee's work fax number. |
|
20 |
| Occupation |
Type the employee's occupation. |
|
40 |
| Hire Date |
Type the date the employee began working for this employer or click the calendar icon to select a date. |
|
10 |
| Termination Date |
Type the date the employee was terminated from this employer, if applicable, or click the calendar icon to select a date. |
|
10 |
| Supervisor |
Type the name of the employee's supervisor. |
|
30 |
| Comments |
Type any applicable comment for this employer record. |
|
50 |
| Comments |
Type any additional applicable comment for this employer record. |
|
50 |
| Employee Relationship |
Select the option to indicate if this is the patient's employer, the guarantor's employer or the insured's employer. |
 |
1 |