| Prompt |
Response |
Req |
Len |
| Protocol Code |
Type the code you want or click the
magnifying glass to search the table. This code cannot begin with
a zero. |
 |
4 |
| Protocol Description |
Type a description of the protocol code. |
 |
40 |
| Employer |
Type the employer code or click the
magnifying glass to search the table. |
 |
8 |
| Employer Address Line One |
Type the address for the employer. If
you selected an existing employer code, the information from the
Employer Code Table for that employer will default in this field. |
|
40 |
| Line Two |
Type any additional address information.
If you selected an existing employer code, the information from
the Employer Code Table defaults in this field. |
|
40 |
| City, State, Zip |
Type the city, select the state from
the State list, and type the zip code. If you selected an existing
employer code, this information defaults from the Employer Code
Table. |
|
15 / 3 / 10 |
| Contact |
Type the name of the contact person
for this employer. If you selected an existing employer code,
the information from the Employer Code Table defaults in this
field. |
|
40 |
| Phone |
Type the telephone number for this contact.
If you selected an existing employer code, the information from
the Employer Code Table defaults in this field. |
|
14 |
| Fax |
Type the fax number for this contact.
If you selected an existing employer code, the information from
the Employer Code Table defaults in this field. |
|
14 |
| Address B Line One |
Type the address to be used for additional
services for this Protocol. |
|
40 |
| Line Two |
Type any additional address information
to be used for additional services for this Protocol. |
|
40 |
| City, State, Zip |
Type the city, select the state from
the State list, and type the zip code to be used for additional
services for this Protocol. |
|
15 / 3 / 10 |
| Contact |
Type the name of the contact person
to be used for additional services for this Protocol. |
|
40 |
| Phone |
Type the telephone number for this contact. |
|
14 |
| Fax |
Type the fax number for this contact. |
|
14 |
| Address C Line One |
Type the address to be used for additional
services for this Protocol. |
|
40 |
| Line Two |
Type any additional address information
to be used for additional services for this Protocol. |
|
40 |
| City, State, Zip |
Type the city, select the state from
the State list, and type the zip code to be used for additional
services for this Protocol. |
|
15 / 3 / 10 |
| Contact |
Type the name of the contact person
to be used for additional services for this Protocol. |
|
40 |
| Phone |
Type the telephone number for this contact. |
|
14 |
| Fax |
Type the fax number for this contact. |
|
14 |
| Address D Line One |
Type the address to be used for additional
services for this Protocol. |
|
40 |
| Line Two |
Type any additional address information
to be used for additional services for this Protocol. |
|
40 |
| City, State, Zip |
Type the city, select the state from
the State list, and type the zip code to be used for additional
services for this Protocol. |
|
15 / 3 / 10 |
| Contact |
Type the name of the contact person
to be used for additional services for this Protocol. |
|
40 |
| Phone |
Type the telephone number for this contact. |
|
14 |
| Fax |
Type the fax number for this contact. |
|
14 |
| Insurance Carrier |
Type the insurance carrier code you
want or click the magnifying glass to search the table. |
|
5 |
| User Name |
Type the name of the User who created
this Protocol Code information. |
|
15 |
| Email |
Type the e-mail address of the User
who created this Protocol Code information. |
|
36 |
| Effective Date |
Type the effective date for this protocol
or click the calendar icon to select a date. |
 |
10 |
| Additional Information: |
Type any applicable instructions that
correspond with this field. You control the name of the field
(Field Description) from the Protocol Integration function. |
|
80 x 3 |
| Additional Information: |
Type any applicable instructions that
correspond with this field. You control the name of the field
(Field Description) from the Protocol Integration function. |
|
80 x 3 |
| Additional Information: |
Type any applicable instructions that
correspond with this field. You control the name of the field
(Field Description) from the Protocol Integration function. |
|
80 x 3 |
| Additional Information: |
Type any applicable instructions that
correspond with this field. You control the name of the field
(Field Description) from the Protocol Integration function. |
|
80 x 3 |
| Additional Information: |
Type any applicable instructions that
correspond with this field. You control the name of the field
(Field Description) from the Protocol Integration function. |
|
80 x 3 |
| Additional Information: |
Type any applicable instructions that
correspond with this field. You control the name of the field
(Field Description) from the Protocol Integration function. |
|
80 x 3 |
| Additional Information: |
Type any applicable instructions that
correspond with this field. You control the name of the field
(Field Description) from the Protocol Integration function. |
|
80 x 3 |
| Additional Information: |
Type any applicable instructions that
correspond with this field. You control the name of the field
(Field Description) from the Protocol Integration function. |
|
80 x 3 |
| Additional Information: |
Type any applicable instructions that
correspond with this field. You control the name of the field
(Field Description) from the Protocol Integration function. |
|
80 x 3 |
| Additional Information: |
Type any applicable instructions that
correspond with this field. You control the name of the field
(Field Description) from the Protocol Integration function. |
|
80 x 3 |
| Additional Information: |
Type any applicable instructions that
correspond with this field. You control the name of the field
(Field Description) from the Protocol Integration function. |
|
80 x 3 |
| Additional Information: |
Type any applicable instructions that
correspond with this field. You control the name of the field
(Field Description) from the Protocol Integration function. |
|
80 x 3 |
| Additional Information: |
Type any applicable instructions that
correspond with this field. You control the name of the field
(Field Description) from the Protocol Integration function. |
|
80 x 3 |
| Additional Information: |
Type any applicable instructions that
correspond with this field. You control the name of the field
(Field Description) from the Protocol Integration function. |
|
80 x 3 |
| Additional Information: |
Type any applicable instructions that
correspond with this field. You control the name of the field
(Field Description) from the Protocol Integration function. |
|
80 x 3 |