| 76435-7 | Pt ID | |
| 76698-0 | Pt ID assign auth | |
| 76471-2 | Organization EOC unique ID | |
| 76470-4 | Federal employer tax ID Organization | |
| 76696-4 | Name Fclty | |
| 76427-4 | Visit date | |
| 76417-5 | Provider First name | |
| 76419-1 | Provider Last name | |
| 45952-9 | National provider ID:ID:Pt:Provider:Nom: | |
| 86637-6 | Provider role | |
| 89176-2 | Intervention or services provided pnl | |
| 89175-4 | Billing info pnl | |