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5 through 11 – Other Coverage Information

 

This information pulls from the patients secondary insured information on the patient information screen, secondary ins and includes the secondary insureds Name, Date of Birth, Gender, Subscriber ID#, Plan/Group Number, Patients Relationship to Other Insured and Carrier Name and Address.

NOTE: If you are printing a secondary placeCityADA form this information will pull from the Primary Insureds information on the patient information.