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3 – Name, Address, City, State, Zip Code


This information pulls from the patients Primary Insurance information on the Patient Information screen, Primary Ins.

Select the insurance company from the Insurance Master List by using the look up folder next to Ins Code to select the appropriate insurance company. The address for the selected insurance company will pull in to these fields.

NOTE: If this is a secondary placeCityADA form this information will pull from the Secondary Insurance information on the Patient Information.