| 54503-8 | Legal name of patient:-:Pt:^Patient:-: | |
| 45966-9 | Social Security & Medicare numbers:-:Pt:^Patient:-: | |
| 45400-9 | Medicaid # | |
| 46098-0 | Sex | |
| 21112-8 | Birth date | |
| 69854-8 | Hispanic, latino-a, or spanish | |
| 103708-4 | Race:Type:RptPeriod:^Patient:Nom:CMS Assessment | |
| 93186-5 | Preferred lang + interp need | |
| 45404-1 | Marital status | |
| 101351-5 | Has lack of transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living:Find:RptPeriod:^Patient:Nom:CMS Assessment | |
| 52556-8 | Payment sources:Type:Pt:^Patient:Nom: | |