| 52526-1 | Attending physician name | required |
| 68340-9 | Attending physician phone number:Tele:Pt:Provider:Nom: | required |
| 68468-8 | Attending physician NPI:ID:Pt:Provider:Nom: | required |
| 68355-7 | Date signed:TmStp:Pt:Form:Qn: | required |
| 8251-1 | Service Cmnt-Imp | optional |
| 68355-7 | Date signed:TmStp:Pt:Form:Qn: | required |
| 65838-5 | Date submitted:Date:Pt:Form:Qn: | required |