| 45965-1 | Name:-:Pt:^Patient:Set: | |
| 46098-0 | Sex | |
| 21112-8 | Birth date | |
| 32624-9 | Race | |
| 45966-9 | Social Security & Medicare numbers:-:Pt:^Patient:-: | |
| 45967-7 | Facility provider numbers:-:Pt:Facility:Set: | |
| 45400-9 | Medicaid # | |
| 45968-5 | Reasons for assessment (basic):-:Pt:^Patient:Set: | |