interface/billing/ub04_form.php

   1 <?php
   2 /**
   3  * UB04 Claims Form
   4  *
   5  * @package OpenEMR
   6  * @link    http://www.open-emr.org
   7  * @author  Jerry Padgett <sjpadgett@gmail.com>
   8  * @copyright Copyright (c) 2017 Jerry Padgett <sjpadgett@gmail.com>
   9  * @license https://www.gnu.org/licenses/agpl-3.0.en.html GNU Affero General Public License 3
  10  */
  11 /* $isAuthorized tells us if the form is for user UI or claim processing and provides another security check */
  12 if ($isAuthorized !== true) {
  13     require_once("./ub04_dispose.php");
  14     $isAuthorized = 0;
  15     $pid = $_REQUEST['pid'] ? $_REQUEST['pid'] : '0';
  16     $encounter = $_REQUEST['enc'] ? $_REQUEST['enc'] : '0';
  17     $action = $_REQUEST['action'] ? $_REQUEST['action'] : false;
  18     $payerid = $_REQUEST['id'] ? $_REQUEST['id'] : '0';
  19     $imgurl = $GLOBALS['images_static_relative'];
  20     if ($action == 'payer_defaults') {
  21         $ub04id = get_payer_defaults($payerid);
  22     } elseif ($pid && $encounter) {
  23         $ub04id = json_encode(get_ub04_array($pid, $encounter));
  24     } else {
  25         exit(xlt("Sorry! Not Authorized."));
  26     }
  27 } else {
  28     $imgurl = "../../../../public/images";
  29 }
  30
  31 ?>
  32 <!DOCTYPE html >
  33 <html>
  34 <head>
  35 <meta http-equiv="X-UA-Compatible" content="IE=Edge" />
  36 <meta charset="utf-8" />
  37 <?php if ($isAuthorized !== true) {?>
  38 <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery/dist/jquery.min.js"></script>
  39 <script type="text/javascript" src="<?php echo $webroot ?>/interface/main/tabs/js/include_opener.js?v=<?php echo $v_js_includes; ?>"></script>
  40  <link rel="stylesheet" href="<?php echo $GLOBALS['assets_static_relative']; ?>/bootstrap/dist/css/bootstrap.min.css">
  41  <link href="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-ui-themes/themes/base/jquery-ui.min.css" rel="stylesheet" type="text/css" />
  42 <link rel="stylesheet" href="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-datetimepicker/build/jquery.datetimepicker.min.css">
  43 <script src="<?php echo $GLOBALS['assets_static_relative']; ?>/bootstrap/dist/js/bootstrap.min.js" type="text/javascript"></script>
  44 <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative']; ?>/emodal/dist/eModal.min.js"></script>
  45 <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative']; ?>/jquery-datetimepicker/build/jquery.datetimepicker.full.min.js"></script>
  46 <script type="text/javascript" src="<?php echo $GLOBALS['assets_static_relative'] ?>/jquery-ui/jquery-ui.min.js"></script>
  47
  48 <script type="text/javascript">
  49 $( document ).ready(function() {
  50     $( "[title*='DATE']" ).datetimepicker({
  51         <?php $datetimepicker_timepicker = false; ?>
  52         <?php $datetimepicker_showseconds = false; ?>
  53         <?php $datetimepicker_formatInput = false; ?>
  54         <?php require($GLOBALS['srcdir'] . '/js/xl/jquery-datetimepicker-2-5-4.js.php'); ?>
  55         <?php echo(",validateOnBlur: false, formatDate: 'mdy', format: 'mdy'") ?>
  56     });
  57
  58     $(".user").on( 'dblclick', function( event ) {
  59         event.preventDefault();
  60         selectUser(this.id,event);
  61     });
  62     $("#dismissHelp").click(function(e){
  63         e.preventDefault();
  64         $('#formHelp').toggle();
  65     });
  66
  67     $( function() {
  68         var cache = {};
  69         $( "[title*='REVENUE CODE']" ).autocomplete({
  70           minLength: 1,
  71           source: function( request, response ) {
  72             var term = request.term;
  73             request.code_group = "revenue_code";
  74             if ( term in cache ) {
  75               response( cache[ term ] );
  76               return;
  77             }
  78             $.getJSON( "./ub04_helpers.php", request, function( data, status, xhr ) {
  79               cache[ term ] = data;
  80               response( data );
  81             });
  82           }
  83         }).dblclick(function(event) {
  84             $(this).autocomplete('search'," ");
  85         });
  86       });
  87     $( function() {
  88         var cache = {};
  89         $( "[title*='OCCURRENCE CODE']" ).autocomplete({
  90             minLength: 1,
  91             source: function( request, response ) {
  92               var term = request.term;
  93               request.code_group = "occurrence_code";
  94               if ( term in cache ) {
  95                 response( cache[ term ] );
  96                 return;
  97               }
  98               $.getJSON( "./ub04_helpers.php", request, function( data, status, xhr ) {
  99                 cache[ term ] = data;
 100                 response( data );
 101               });
 102             }
 103           }).dblclick(function(event) {
 104               $(this).autocomplete('search'," ");
 105           });
 106     });
 107     $( function() {
 108         var cache = {};
 109         $( "[title*='OCCURRENCE SPAN CODE']" ).autocomplete({
 110             minLength: 1,
 111             source: function( request, response ) {
 112               var term = request.term;
 113               request.code_group = "occurrence_span_code";
 114               if ( term in cache ) {
 115                 response( cache[ term ] );
 116                 return;
 117               }
 118               $.getJSON( "./ub04_helpers.php", request, function( data, status, xhr ) {
 119                 cache[ term ] = data;
 120                 response( data );
 121               });
 122             }
 123           }).dblclick(function(event) {
 124               $(this).autocomplete('search'," ");
 125           });
 126     });
 127     $( function() {
 128         var cache = {};
 129         $( "[title*='VALUE CODE']" ).autocomplete({
 130           minLength: 1,
 131           source: function( request, response ) {
 132             var term = request.term;
 133             request.code_group = "value_codes";
 134             if ( term in cache ) {
 135               response( cache[ term ] );
 136               return;
 137             }
 138             $.getJSON( "./ub04_helpers.php", request, function( data, status, xhr ) {
 139               cache[ term ] = data;
 140               response( data );
 141             });
 142           }
 143         }).dblclick(function(event) {
 144             $(this).autocomplete('search'," ");
 145         });
 146       });
 147     $( function() {
 148         var cache = {};
 149         $( "[title*='CONDITION CODE']" ).autocomplete({
 150           minLength: 1,
 151           source: function( request, response ) {
 152             var term = request.term;
 153             request.code_group = "condition_code";
 154             if ( term in cache ) {
 155               response( cache[ term ] );
 156               return;
 157             }
 158             $.getJSON( "./ub04_helpers.php", request, function( data, status, xhr ) {
 159               cache[ term ] = data;
 160               response( data );
 161             });
 162           }
 163         }).dblclick(function(event) {
 164             $(this).autocomplete('search'," ");
 165         });
 166       });
 167     $( function() {
 168         var cache = {};
 169         $( "[title*='STATUS']" ).autocomplete({
 170           minLength: 1,
 171           source: function( request, response ) {
 172             var term = request.term;
 173             request.code_group = "patient_status_code";
 174             if ( term in cache ) {
 175               response( cache[ term ] );
 176               return;
 177             }
 178             $.getJSON( "./ub04_helpers.php", request, function( data, status, xhr ) {
 179               cache[ term ] = data;
 180               response( data );
 181             });
 182           }
 183         }).dblclick(function(event) {
 184             $(this).autocomplete('search'," ");
 185         });
 186       });
 187
 188     $('form :input').change(function(e){
 189            formChanged = true;
 190            $(this).css("color","red");
 191            return false;
 192     });
 193 });
 194 <?php } else {?>
 195 <script type="text/javascript">
 196 <?php } ?>
 197 var pid;
 198 var encounter;
 199 var align = true;
 200 var isTemplate;
 201 var ub04id = new Array();
 202 payerid = '<?php echo attr($payerid);?>';
 203 pid = <?php echo attr($pid);?>;
 204 encounter = <?php echo attr($encounter);?>;
 205 isTemplate = <?php echo attr(($isAuthorized === true ? $isAuthorized : 0)); ?>;
 206 ub04id = <?php echo $ub04id;?>;
 207
 208 function adjustForm()
 209 {
 210     // cycle trough the input fields
 211     // rem form index i is not same as formid index ii
 212     var inputs = Array.prototype.slice.call(document.forms[0])
 213
 214     Array.prototype.forEach.call(inputs, function(el, i) {
 215         var type = el.getAttribute('type');
 216         var ta = window.getComputedStyle(el,null).getPropertyValue("text-align");
 217         var title = el.getAttribute('title')
 218         var max = el.getAttribute('maxlength');
 219         var w = el.clientWidth
 220         var size = w;
 221             if( ta == 'right' ){
 222                 if(title.indexOf("CHARGES") !== -1){
 223                      w = size - 14;
 224                      if(!isTemplate){ w = size - 8; }
 225                 }
 226                 else{
 227                     w = size - 8;
 228                     if(!isTemplate){ w = size - 4; }
 229                 }
 230                 el.style.width = w + 'px'
 231             }
 232         el.style.top = (el.offsetTop+3)+'px'
 233         if( ta == 'left' )
 234             el.style.left = (el.offsetLeft+2)+'px'
 235         var ii = i+1;
 236         if(typeof(ub04id[ii]) != 'undefined' && ub04id[ii] != ""){
 237             var val = ub04id[ii]
 238             if( val.length > max && max > 0 ){
 239                 val = ub04id[ii].substring(0,max);
 240             }
 241             document.getElementById("ub04id"+ ii.toString()).value = val
 242             return;
 243         }
 244  });
 245  return false;
 246 }
 247 <?php if ($isAuthorized !== true) {?>
 248 var formChanged = false;
 249
 250 function rewrite(ub04id){
 251     var inputs = Array.prototype.slice.call(document.forms[0])
 252     Array.prototype.forEach.call(inputs, function(el, i) {
 253         var max = el.getAttribute('maxlength');
 254         var ii = i+1;
 255         if(typeof(ub04id[ii]) != 'undefined'){
 256             var val = ub04id[ii]
 257             if( val.length > max && max > 0 ){
 258                 val = ub04id[ii].substring(0,max);
 259             }
 260             document.getElementById("ub04id"+ ii.toString()).value = val
 261             return;
 262         }
 263     });
 264 }
 265
 266 function cleanUp()
 267 {
 268     if(payerid == '0'){
 269        window.opener.SubmitTheScreen();
 270     }
 271     window.close()
 272 }
 273
 274 function selectUser(formid,event)
 275 {
 276     var title = 'Providers';
 277      var params = {
 278                buttons: [
 279                    { text: 'Cancel', close: true, style: 'default btn-sm'} ],
 280                //size: eModal.size.sm,
 281                subtitle: 'Provider Info.',
 282                title: title,
 283                useBin: false,
 284                url: './ub04_helpers.php?action=user_select&formid=' + encodeURIComponent(formid)
 285            };
 286        return eModal.ajax(params)
 287            .then(function () { });
 288 }
 289
 290 function updateProvider(formid, selected)
 291 {
 292     document.getElementById(formid).value = selected.npi;
 293     if(formid == 'ub04id379'){
 294         document.getElementById('ub04id388').value = selected.lname;
 295         document.getElementById('ub04id389').value = selected.fname;
 296         document.getElementById('ub04id289').value = selected.taxonomy;
 297     }
 298     else if(formid == 'ub04id390'){
 299         document.getElementById('ub04id400').value = selected.lname;
 300         document.getElementById('ub04id401').value = selected.fname;
 301         document.getElementById('ub04id296').value = selected.taxonomy;
 302     }
 303     else if(formid == 'ub04id406'){
 304         document.getElementById('ub04id413').value = selected.lname;
 305         document.getElementById('ub04id414').value = selected.fname;
 306         document.getElementById('ub04id303').value = selected.taxonomy;
 307     }
 308     else if(formid == 'ub04id420'){
 309         document.getElementById('ub04id427').value = selected.lname;
 310         document.getElementById('ub04id428').value = selected.fname;
 311     }
 312     return false;
 313 }
 314 function disposeSave(action)
 315 {
 316     var htmlout = "";
 317     var inputs;
 318     var slice = Array.prototype.slice;
 319     inputs = slice.call(document.forms[0])
 320     Array.prototype.forEach.call(inputs, function(el, i) {
 321         var ii = i+1;
 322         var tmp = document.getElementById("ub04id"+ ii.toString()).value;
 323         if(tmp){
 324             ub04id[ii] = document.getElementById("ub04id"+ ii.toString()).value.toUpperCase();
 325         }
 326     });
 327     ub04idSave = JSON.stringify(ub04id);
 328     var qstr = param({ handler: 'edit_save',pid:pid,encounter:encounter,action:action,ub04id:ub04idSave });
 329     location.href='ub04_dispose.php?'+qstr;
 330 }
 331
 332 function postClaim(action)
 333 {
 334     var inputs;
 335     var c = [];
 336     var slice = Array.prototype.slice;
 337     inputs = slice.call(document.forms[0])
 338     Array.prototype.forEach.call(inputs, function(el, i) {
 339         var ii = i+1;
 340         var tmp = document.getElementById("ub04id"+ ii.toString()).value;
 341         if(tmp){
 342             var row = el.offsetTop.toString();
 343             var col = el.offsetLeft.toString();
 344             var max = el.getAttribute('maxlength');
 345             var ta = window.getComputedStyle(el,null).getPropertyValue("text-align");
 346             var w = window.getComputedStyle(el,null).getPropertyValue("width");
 347             var ob = {fld:ii,top:row,left:col,max:max,align:ta,width:w}
 348             c.push(ob)
 349             ub04id[ii] = document.getElementById("ub04id"+ ii.toString()).value.toUpperCase();
 350         }
 351     });
 352     var cj = JSON.stringify(c)
 353     ub04idSave = JSON.stringify(ub04id);
 354     var xhr = new XMLHttpRequest();
 355     xhr.open('POST', 'ub04_dispose.php');
 356     xhr.setRequestHeader("Content-Type", "application/x-www-form-urlencoded");
 357     xhr.onload = function() {
 358         if (xhr.status === 200) {
 359             console.log(this.responseText ? this.responseText : 'no response');
 360             if(this.responseText == 'done')
 361                 alert("<?php echo xls("Save Completed")?>");
 362         }
 363     };
 364     if(action == 'payer_save'){
 365         var qs = param({handler:action,payerid:payerid,ub04id: ub04idSave})
 366     }
 367     else if(action == 'batch_save'){
 368         var qs = param({handler:action,pid:pid,encounter:encounter,ub04id:ub04idSave,loc:cj})
 369     }
 370     xhr.send(qs);
 371 }
 372
 373 function param(object)
 374 {
 375     var encodedString = '';
 376     for (var prop in object) {
 377         if (object.hasOwnProperty(prop)) {
 378             if (encodedString.length > 0) {
 379                 encodedString += '&';
 380             }
 381             encodedString += encodeURI(prop + '=' + object[prop]);
 382         }
 383     }
 384     return encodedString;
 385 }
 386
 387 var scale = 1.25;
 388 function myZoom()
 389 {
 390     var el = document.getElementById('p1');
 391     scale += 0.05;
 392     if(scale > 1.25) scale = 1.0;
 393     el.style.transform = 'scale(' + scale + ')';
 394 }
 395
 396 function resetClaim(){
 397     var msg = '<?php echo xlt('This action will reset your claim!') . '\n' . xlt('Click OK if you are sure.')?>';
 398     var yn = confirm(msg);
 399     if (yn != true) {
 400         return false;
 401     }
 402     $.ajax({
 403         type: 'GET',
 404         url: 'ub04_dispose.php',
 405         data: {handler:'reset_claim',pid:pid,encounter:encounter},
 406         dataType: 'json',
 407         success: function( rtn ) {
 408           ub04id = rtn;
 409           document.getElementById('ub04Data').reset();
 410           rewrite(ub04id);
 411         }
 412     });
 413 }
 414
 415 <?php } ?>
 416 </script>
 417
 418 <style>
 419 .container {
 420 text-align:center;
 421 }
 422
 423 .ui-autocomplete {max-height: 250px; max-width: 25%; width: 50%; overflow-y: auto; overflow-x: hidden;}
 424
 425 input{
 426     z-index:2;
 427     text-transform: uppercase;
 428     position: absolute; border-width:0px;
 429     height:14px; color: rgb(0,0,0);
 430     background: transparent; border-color:transparent;
 431     font:normal 10pt 'Times New Roman', Times, serif;
 432 }
 433
 434 textarea{
 435     z-index:2;
 436     text-transform: uppercase;
 437     position: absolute; border-width:0px;
 438     color: rgb(0,0,0);
 439     background: transparent; border-color:transparent;
 440     font:normal 10pt 'Times New Roman', Times, serif;
 441 }
 442
 443 input:focus{color: blue !important;}
 444
 445 body {
 446     padding: 0px;
 447     margin-top: 35px;
 448     margin-bottom: 35px;
 449     background-color: lightgrey;
 450 }
 451
 452 #p1 {
 453     transform: scale(1.2);
 454     transform-origin: top center;
 455     margin-top: 0px;
 456     margin-left: auto;
 457     margin-right: auto;
 458 }
 459
 460 #menu {
 461     text-align: center;
 462     z-index: 9999;
 463     background-color: ghostwhite;
 464     position: fixed;
 465     padding:5px 5px 5px 5px;
 466     margin-left: auto;
 467     margin-right: auto;
 468     /* opacity: 0.8; */
 469     top: 0px;
 470 }
 471
 472 @media print {
 473 .datepicker{
 474     border-color:transparent !important;
 475     background-color:transparent !important;
 476 }
 477 .user{
 478     background-color:transparent !important;
 479     border-color:transparent !important;
 480 }
 481 body {
 482     padding: 0px;
 483     margin: 0px;
 484     background-color: #fff;
 485 }
 486 .formhide {
 487     display: none;
 488 }
 489 #p1 {
 490     margin-top: 0px;
 491     margin-left: 0px;
 492     margin-right: 0px;
 493 }
 494 input{
 495     z-index:2;
 496     text-transform: uppercase;
 497     position: absolute; border-width:0px;
 498     height:14px; color: rgb(0,0,0);
 499     background: transparent; border-color:transparent;
 500     font:normal 10pt 'Times New Roman', Times, serif;
 501 }
 502 textarea{
 503     z-index:2;
 504     text-transform: uppercase;
 505     position: absolute; border-width:0px;
 506     color: rgb(0,0,0);
 507     background: transparent; border-color:transparent;
 508     font:normal 10pt 'Times New Roman', Times, serif;
 509 }
 510 }
 511
 512 #ub04id1{ left:301px; top:19px; width:264px;  text-align:left;}
 513 #ub04id2{ left:26px;  top:19px; width:264px;  text-align:left;}
 514 #ub04id3{ left:599px; top:19px; width:263px;  text-align:left;}
 515 #ub04id4{ left:26px;  top:37px; width:264px;  text-align:left;}
 516 #ub04id5{ left:301px; top:37px; width:264px;  text-align:left;}
 517 #ub04id6{ left:599px; top:37px; width:263px;  text-align:left;}
 518 #ub04id7{ left:862px; top:37px; width:57px;  text-align:center;}
 519 #ub04id8{ left:26px;  top:57px; width:264px;  text-align:left;}
 520 #ub04id9{ left:301px; top:57px; width:264px;  text-align:left;}
 521 #ub04id10{left:26px;  top:74px; width:264px;  text-align:left;}
 522 #ub04id11{left:301px; top:74px; width:264px;  text-align:left;}
 523 #ub04id12{left:567px; top:74px; width:110px;  text-align:left;}
 524 #ub04id13{left:675px; top:74px; width:77px;  text-align:center;}
 525 #ub04id14{left:753px; top:74px; width:77px;  text-align:center;}
 526 #ub04id15{resize:none; left:842px; top:55px; width:77px; height:32px; color: rgb(0,0,0); text-align:left;}
 527 #ub04id16{left:138px; top:92px; width:208px;  text-align:left;}
 528 #ub04id17{left:468px; top:92px; width:451px;  text-align:left;}
 529 #ub04id18{left:28px;  top:110px; width:318px;  text-align:left;}
 530 #ub04id19{left:358px; top:110px; width:352px;  text-align:left;}
 531 #ub04id20{left:720px; top:110px; width:34px;  text-align:left;}
 532 #ub04id21{left:764px; top:110px; width:110px;  text-align:left;}
 533 #ub04id22{left:885px; top:110px; width:34px;  text-align:left;}
 534 #ub04id23{left:15px;  top:147px; width:99px;  text-align:right;}
 535 #ub04id24{left:115px; top:147px; width:34px;  text-align:center;}
 536 #ub04id25{left:148px; top:147px; width:66px;  text-align:right;}
 537 #ub04id26{left:214px; top:147px; width:32px;  text-align:center;}
 538 #ub04id27{left:246px; top:147px; width:34px;  text-align:center;}
 539 #ub04id28{left:280px; top:147px; width:32px;  text-align:center;}
 540 #ub04id29{left:312px; top:147px; width:34px;  text-align:center;}
 541 #ub04id30{left:345px; top:147px; width:34px;  text-align:right;}
 542 #ub04id31{left:378px; top:147px; width:34px;  text-align:center;}
 543 #ub04id32{left:411px; top:147px; width:34px;  text-align:center;}
 544 #ub04id33{left:445px; top:147px; width:34px;  text-align:center;}
 545 #ub04id34{left:477px; top:147px; width:34px;  text-align:center;}
 546 #ub04id35{left:510px; top:147px; width:34px;  text-align:center;}
 547 #ub04id36{left:543px; top:147px; width:34px;  text-align:center;}
 548 #ub04id37{left:576px; top:147px; width:34px;  text-align:center;}
 549 #ub04id38{left:610px; top:147px; width:34px;  text-align:center;}
 550 #ub04id39{left:643px; top:147px; width:34px;  text-align:center;}
 551 #ub04id40{left:675px; top:147px; width:34px;  text-align:center;}
 552 #ub04id41{left:709px; top:147px; width:32px;  text-align:center;}
 553 #ub04id42{left:741px; top:147px; width:37px;  text-align:center;}
 554 #ub04id43{left:778px; top:147px; width:141px;  text-align:left;}
 555 #ub04id44{left:15px;  top:184px; width:32px;  text-align:center;}
 556 #ub04id45{left:49px;  top:184px; width:77px;  text-align:right;}
 557 #ub04id46{left:125px; top:184px; width:32px;  text-align:center;}
 558 #ub04id47{left:159px; top:184px; width:77px;  text-align:right;}
 559 #ub04id48{left:235px; top:184px; width:32px;  text-align:center;}
 560 #ub04id49{left:269px; top:184px; width:77px;  text-align:right;}
 561 #ub04id50{left:345px; top:184px; width:34px;  text-align:center;}
 562 #ub04id51{left:379px; top:184px; width:77px;  text-align:right;}
 563 #ub04id52{left:455px; top:184px; width:34px;  text-align:center;}
 564 #ub04id53{left:489px; top:184px; width:77px;  text-align:right;}
 565 #ub04id54{left:567px; top:184px; width:77px;  text-align:right;}
 566 #ub04id55{left:643px; top:184px; width:32px;  text-align:center;}
 567 #ub04id56{left:677px; top:184px; width:77px;  text-align:right;}
 568 #ub04id57{left:755px; top:184px; width:77px;  text-align:right;}
 569 #ub04id58{left:831px; top:184px; width:87px;  text-align:center;}
 570 #ub04id59{left:15px;  top:202px; width:32px;  text-align:center;}
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 572 #ub04id61{left:125px; top:202px; width:32px;  text-align:center;}
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 941 </style>
 942 </head>
 943 <body onload="adjustForm();">
 944 <div class="container" id="formContainer">
 945 <?php if ($isAuthorized !== true) {?>
 946 <h3 class='formhide'><em><?php echo xlt('Claim Edit') ?> </em><button class="btn btn-xs btn-warning" onclick="myZoom()" ><?php echo xlt('Zoom'); ?></button></h3>
 947 <div class="navbar-fixed-top formhide" id='menu'>
 948 <?php if ($pid && $encounter) {?>
 949     <button class="btn btn-xs btn-success" onclick="disposeSave('form')" title=<?php echo xla("Save for printing with form") ?>><?php echo xlt('Pdf With Form'); ?></button>
 950     <button class="btn btn-xs btn-success" onclick="disposeSave('noform')" title=<?php echo xla("Save for printing to a pre printed sheet"); ?>><?php echo xlt('Pdf Without Form'); ?></button>
 951     <button class="btn btn-xs btn-success" onclick="postClaim('batch_save')" title=<?php echo xla("Save claim for batch processing"); ?>><?php echo xlt('Save Claim'); ?></button>
 952     <?php } else {?>
 953     <button class="btn btn-xs btn-success" onclick="postClaim('payer_save')"><?php echo xlt('Save Payer'); ?></button>
 954     <?php } ?>
 955     <button class="btn btn-xs btn-danger" onclick="resetClaim()" title=<?php echo xla("Reset claim form to Fee Sheet Version"); ?>><?php echo xlt('Reset Version'); ?></button>
 956     <button class="btn btn-info btn-xs" type="button" onclick="window.scrollTo(0, 0);$('#formhelp').toggle()"><?php echo xlt('Help'); ?></button>
 957     <button class="btn btn-xs btn-danger" onclick="cleanUp()"><?php echo xlt('Return'); ?></button>
 958 </div>
 959 <div id='formhelp' class='well' style='display:none; text-align:center; width: auto; margin: 5px auto;'>
 960     <h4>Help</h4>
 961      <div style='text-align:left;'>
 962         * <?php echo xlt('Many code items have a lookup/hint.'); ?>
 963         <?php echo xlt('Either type a search term in appropriate box or double click box to see available codes.'); ?><br>
 964         * <?php echo xlt('Double Clicking a NPI box will bring up a current Users dialog for providers.'); ?><br>
 965         * <?php echo xlt('PDF buttons will save, mark claim reviewed and download claim'); ?><br>
 966         * <?php echo xlt('Reset button resets the edited claim to the fee sheet version. If subsequently saved, it will replace last claim version and be considered reviewed. Otherwise, claim is reset to fee sheet version.'); ?><br>
 967         * <?php echo xlt('Save button saves claim and marks reviewed'); ?><br>
 968         * <?php echo xlt('Return button simply returns, then refreshes billing manager'); ?><br><br>
 969     </div>
 970    <button class="btn btn-primary btn-xs" type="button" onclick="$('#formhelp').toggle()"><?php echo xlt('Dismiss Help'); ?></button>
 971 </div>
 972 <?php } ?>
 973 <div id="p1" class="pageArea" style="overflow: hidden; position: relative; width: 934px; height: 1210px;">
 974 <!-- Template background -->
 975 <div id="pg1" style="-webkit-user-select: none;"><img src="<?php echo $imgurl ?>/ub04.svg" id="frmbg" style="width:934px; height:1210px; background-color:white; -moz-transform:scale(1); z-index: 0;" /></div>
 976 <!-- Begin Form Data -->
 977 <form id="ub04Data">
 978 <input type="text"   maxlength="25"  id="ub04id1" value=""  title="2. PAY-TO NAME"  name="ub04Block_4"/>
 979 <input type="text"   maxlength="25"  id="ub04id2" value=""  title="1. BILLING PROVIDER NAME"  name="ub04Block_0"/>
 980 <input type="text"   maxlength="20"  id="ub04id3" value=""  title="3a. PATIENT CONTROL NUMBER"  name="ub04Block_8"/>
 981 <input type="text"   maxlength="25"  id="ub04id4" value=""  title="1. BILLING PROVIDER STREET ADDRESS"  name="ub04Block_1"/>
 982 <input type="text"   maxlength="25"  id="ub04id5" value=""  title="2. PAY-TO STREET ADDRESS"  name="ub04Block_5"/>
 983 <input type="text"   maxlength="24"  id="ub04id6" value=""  title="3b. MEDICAL/HEALTH RECORD NUMBER"  name="ub04Block_9"/>
 984 <input type="text"   maxlength="4"  id="ub04id7" value=""   title="4. TYPE OF BILL"  name="ub04Block_10"/>
 985 <input type="text"   maxlength="25"  id="ub04id8" value=""  title="1. BILLING PROVIDER CITY, STATE, ZIP"  name="ub04Block_2"/>
 986 <input type="text"   maxlength="25"  id="ub04id9" value=""  title="2. PAY-TO CITY, STATE, ZIP"  name="ub04Block_6"/>
 987 <input type="text"   maxlength="25"  id="ub04id10" value="" title="1. BILLING PROVIDER COUNTRY CODE, PHONE NUMBER"  name="ub04Block_3"/>
 988 <input type="text"   maxlength="25"  id="ub04id11" value="" title="2. PAY-TO COUNTRY CODE, PHONE NUMBER"  name="ub04Block_7"/>
 989 <input type="text"   maxlength="10"  id="ub04id12" value="" title="5. FEDERAL TAX NUMBER"  name="ub04Block_11"/>
 990 <input type="text" data-dp  maxlength="10"  id="ub04id13" value=""  title="6. STATEMENT COVERS PERIOD FROM DATE"  name="ub04Block_12"/>
 991 <input type="text" data-dp   maxlength="10"  id="ub04id14" value=""  title="6. STATEMENT COVERS PERIOD TO DATE"  name="ub04Block_13"/>
 992 <textarea  disabled maxlength="15"  id="ub04id15" title="7. RESERVED"  name="ub04Block_14"></textarea>
 993 <input type="text"   maxlength="19"  id="ub04id16" value="" title="8a. PATIENT IDENTIFIER"  name="ub04Block_15"/>
 994 <input type="text"   maxlength="40"  id="ub04id17" value="" title="9a. PATIENT STREET ADDRESS"  name="ub04Block_17"/>
 995 <input type="text"   maxlength="29"  id="ub04id18" value="" title="8b. PATIENT NAME"  name="ub04Block_16"/>
 996 <input type="text"   maxlength="30"  id="ub04id19" value="" title="9b. PATIENT CITY"  name="ub04Block_18"/>
 997 <input type="text"   maxlength="2"  id="ub04id20" value=""  title="9c. PATIENT STATE"  name="ub04Block_19"/>
 998 <input type="text"   maxlength="9"  id="ub04id21" value=""  title="9d. PATIENT ZIP CODE"  name="ub04Block_20"/>
 999 <input type="text"   maxlength="2"  id="ub04id22" value=""  title="9e. PATIENT COUNTRY CODE"  name="ub04Block_21"/>
1000 <input type="text"   maxlength="8"  id="ub04id23" value=""  title="10. PATIENT BIRTH DATE (MMDDYYYY)"  name="ub04Block_22"/>
1001 <input type="text"   maxlength="1"  id="ub04id24" value=""  title="11. PATIENT SEX"  name="ub04Block_23"/>
1002 <input type="text" data-dp   maxlength="10"  id="ub04id25" value=""  title="12. PATIENT ADMISSION/START OF CARE DATE (MMDDYY)"  name="ub04Block_24"/>
1003 <input type="text"   maxlength="2"  id="ub04id26" value=""  title="13. PATIENT ADMISSION HOUR"  name="ub04Block_25"/>
1004 <input type="text"   maxlength="1"  id="ub04id27" value=""  title="14. PATIENT PRIORITY (TYPE) OF VISIT"  name="ub04Block_26"/>
1005 <input type="text"   maxlength="1"  id="ub04id28" value=""  title="15. PATIENT POINT OF ORIGIN FOR ADMISSION OR VISIT"  name="ub04Block_27"/>
1006 <input type="text"   maxlength="2"  id="ub04id29" value=""  title="16. PATIENT DISCHARGE HOUR"  name="ub04Block_28"/>
1007 <input type="text"   maxlength="2"  id="ub04id30" value=""  title="17. PATIENT DISCHARGE STATUS"  name="ub04Block_29"/>
1008 <input type="text"   maxlength="2"  id="ub04id31" value=""  title="18. CONDITION CODE"  name="ub04Block_30"/>
1009 <input type="text"   maxlength="2"  id="ub04id32" value=""  title="19. CONDITION CODE"  name="ub04Block_31"/>
1010 <input type="text"   maxlength="2"  id="ub04id33" value=""  title="20. CONDITION CODE"  name="ub04Block_32"/>
1011 <input type="text"   maxlength="2"  id="ub04id34" value=""  title="21. CONDITION CODE"  name="ub04Block_33"/>
1012 <input type="text"   maxlength="2"  id="ub04id35" value=""  title="22. CONDITION CODE"  name="ub04Block_34"/>
1013 <input type="text"   maxlength="2"  id="ub04id36" value=""  title="23. CONDITION CODE"  name="ub04Block_35"/>
1014 <input type="text"   maxlength="2"  id="ub04id37" value=""  title="24. CONDITION CODE"  name="ub04Block_36"/>
1015 <input type="text"   maxlength="2"  id="ub04id38" value=""  title="25. CONDITION CODE"  name="ub04Block_37"/>
1016 <input type="text"   maxlength="2"  id="ub04id39" value=""  title="26. CONDITION CODE"  name="ub04Block_38"/>
1017 <input type="text"   maxlength="2"  id="ub04id40" value=""  title="27. CONDITION CODE"  name="ub04Block_39"/>
1018 <input type="text"   maxlength="2"  id="ub04id41" value=""  title="28. CONDITION CODE"  name="ub04Block_40"/>
1019 <input type="text"   maxlength="2"  id="ub04id42" value=""  title="29. ACCIDENT STATE"  name="ub04Block_41"/>
1020 <input type="text" disabled   id="ub04id43" value="" data-objref="520" title="30. RESERVED"  name="ub04Block_42"/>
1021 <input type="text"   maxlength="2"  id="ub04id44" value=""  title="31a. OCCURRENCE CODE"  name="ub04Block_43"/>
1022 <input type="text" data-dp   maxlength="10"  id="ub04id45" value=""  title="31a. OCCURRENCE DATE"  name="ub04Block_44"/>
1023 <input type="text"   maxlength="2"  id="ub04id46" value=""  title="32a. OCCURRENCE CODE"  name="ub04Block_45"/>
1024 <input type="text" data-dp   maxlength="10"  id="ub04id47" value=""  title="32a. OCCURRENCE DATE"  name="ub04Block_46"/>
1025 <input type="text"   maxlength="2"  id="ub04id48" value=""  title="33a. OCCURRENCE CODE"  name="ub04Block_47"/>
1026 <input type="text" data-dp   maxlength="10"  id="ub04id49" value=""  title="33a. OCCURRENCE DATE"  name="ub04Block_48"/>
1027 <input type="text"   maxlength="2"  id="ub04id50" value=""  title="34a. OCCURRENCE CODE"  name="ub04Block_49"/>
1028 <input type="text" data-dp  maxlength="10"  id="ub04id51" value=""  title="34a. OCCURRENCE DATE"  name="ub04Block_50"/>
1029 <input type="text"   maxlength="2"  id="ub04id52" value=""  title="35a. OCCURRENCE SPAN CODE"  name="ub04Block_59"/>
1030 <input type="text" data-dp   maxlength="10"  id="ub04id53" value=""  title="35a. OCCURRENCE SPAN DATE FROM"  name="ub04Block_60"/>
1031 <input type="text" data-dp  maxlength="10"  id="ub04id54" value=""  title="35a. OCCURRENCE SPAN DATE THROUGH"  name="ub04Block_61"/>
1032 <input type="text"   maxlength="2"  id="ub04id55" value=""  title="36a. OCCURRENCE SPAN CODE"  name="ub04Block_62"/>
1033 <input type="text" data-dp   maxlength="10"  id="ub04id56" value=""  title="36a. OCCURRENCE SPAN DATE FROM"  name="ub04Block_63"/>
1034 <input type="text" data-dp   maxlength="10"  id="ub04id57" value=""  title="36a. OCCURRENCE SPAN DATE THROUGH"  name="ub04Block_64"/>
1035 <input type="text" disabled  maxlength="8"  id="ub04id58" value=""  title="37a. RESERVED"  name="ub04Block_71"/>
1036 <input type="text"   maxlength="2"  id="ub04id59" value=""  title="31b. OCCURRENCE CODE"  name="ub04Block_51"/>
1037 <input type="text" data-dp  maxlength="10"  id="ub04id60" value=""  title="31b. OCCURRENCE DATE"  name="ub04Block_52"/>
1038 <input type="text"   maxlength="2"  id="ub04id61" value=""  title="32b. OCCURRENCE CODE"  name="ub04Block_53"/>
1039 <input type="text" data-dp  maxlength="10"  id="ub04id62" value=""  title="32b. OCCURRENCE DATE"  name="ub04Block_54"/>
1040 <input type="text"   maxlength="2"  id="ub04id63" value=""  title="33b. OCCURRENCE CODE"  name="ub04Block_55"/>
1041 <input type="text" data-dp  maxlength="10"  id="ub04id64" value=""  title="33b. OCCURRENCE DATE"  name="ub04Block_56"/>
1042 <input type="text"   maxlength="2"  id="ub04id65" value=""  title="34b. OCCURRENCE CODE"  name="ub04Block_57"/>
1043 <input type="text" data-dp   maxlength="10"  id="ub04id66" value=""  title="34b. OCCURRENCE DATE"  name="ub04Block_58"/>
1044 <input type="text"   maxlength="2"  id="ub04id67" value=""  title="35b. OCCURRENCE SPAN CODE"  name="ub04Block_65"/>
1045 <input type="text" data-dp   maxlength="10"  id="ub04id68" value=""  title="35b. OCCURRENCE SPAN DATE FROM"  name="ub04Block_66"/>
1046 <input type="text" data-dp   maxlength="10"  id="ub04id69" value=""  title="35b. OCCURRENCE SPAN DATE THROUGH"  name="ub04Block_67"/>
1047 <input type="text"   maxlength="2"  id="ub04id70" value=""  title="36b. OCCURRENCE SPAN CODE"  name="ub04Block_68"/>
1048 <input type="text" data-dp   maxlength="10"  id="ub04id71" value=""  title="36b. OCCURRENCE SPAN DATE FROM"  name="ub04Block_69"/>
1049 <input type="text" data-dp   maxlength="10"  id="ub04id72" value=""  title="36b. OCCURRENCE SPAN DATE THROUGH"  name="ub04Block_70"/>
1050 <input type="text" disabled  maxlength="8"  id="ub04id73" value=""  title="37b. RESERVED"  name="ub04Block_72"/>
1051 <input type="text"   maxlength="2"  id="ub04id74" value=""  title="39a. VALUE CODE"  name="ub04Block_74"/>
1052 <input type="text"   maxlength="9"  id="ub04id75" value=""  title="39a. VALUE AMOUNT"  name="ub04Block_75"/>
1053 <input type="text"   maxlength="2"  id="ub04id76" value=""  title="40a. VALUE CODE"  name="ub04Block_76"/>
1054 <input type="text"   maxlength="9"  id="ub04id77" value=""  title="40a. VALUE AMOUNT"  name="ub04Block_77"/>
1055 <input type="text"   maxlength="2"  id="ub04id78" value=""  title="41a. VALUE CODE"  name="ub04Block_78"/>
1056 <input type="text"   maxlength="9"  id="ub04id79" value=""  title="41a. VALUE AMOUNT"  name="ub04Block_79"/>
1057 <input type="text"   maxlength="2"  id="ub04id80" value=""  title="39b. VALUE CODE"  name="ub04Block_80"/>
1058 <input type="text"   maxlength="9"  id="ub04id81" value=""  title="39b. VALUE AMOUNT"  name="ub04Block_81"/>
1059 <input type="text"   maxlength="2"  id="ub04id82" value=""  title="40b. VALUE CODE"  name="ub04Block_82"/>
1060 <input type="text"   maxlength="9"  id="ub04id83" value=""  title="40b. VALUE AMOUNT"  name="ub04Block_83"/>
1061 <input type="text"   maxlength="2"  id="ub04id84" value=""  title="41b. VALUE CODE"  name="ub04Block_84"/>
1062 <input type="text"   maxlength="9"  id="ub04id85" value=""  title="41b. VALUE AMOUNT"  name="ub04Block_85"/>
1063 <input type="text"   maxlength="2"  id="ub04id86" value=""  title="39c. VALUE CODE"  name="ub04Block_86"/>
1064 <input type="text"   maxlength="9"  id="ub04id87" value=""  title="39c. VALUE AMOUNT"  name="ub04Block_87"/>
1065 <input type="text"   maxlength="2"  id="ub04id88" value=""  title="40c. VALUE CODE"  name="ub04Block_88"/>
1066 <input type="text"   maxlength="9"  id="ub04id89" value=""  title="40c. VALUE AMOUNT"  name="ub04Block_89"/>
1067 <input type="text"   maxlength="2"  id="ub04id90" value=""  title="41c. VALUE CODE"  name="ub04Block_90"/>
1068 <input type="text"   maxlength="9"  id="ub04id91" value=""  title="41c. VALUE AMOUNT"  name="ub04Block_91"/>
1069 <input type="text"   maxlength="2"  id="ub04id92" value=""  title="39d. VALUE CODE"  name="ub04Block_92"/>
1070 <input type="text"   maxlength="9"  id="ub04id93" value=""  title="39d. VALUE AMOUNT"  name="ub04Block_93"/>
1071 <input type="text"   maxlength="2"  id="ub04id94" value=""  title="40d. VALUE CODE"  name="ub04Block_94"/>
1072 <input type="text"   maxlength="9"  id="ub04id95" value=""  title="40d. VALUE AMOUNT"  name="ub04Block_95"/>
1073 <input type="text"   maxlength="2"  id="ub04id96" value=""  title="41d. VALUE CODE"  name="ub04Block_96"/>
1074 <input type="text"   maxlength="9"  id="ub04id97" value=""  title="41d. VALUE AMOUNT"  name="ub04Block_97"/>
1075 <textarea   id="ub04id98"  title="38. RESPONSIBLE PARTY NAME AND ADDRESS"  name="ub04Block_73"></textarea>
1076 <input type="text" class="revcode" maxlength="4"  id="ub04id99" value=""   title="42. REVENUE CODE, Line 1"  name="ub04Block_98"/>
1077 <input type="text"   maxlength="25"  id="ub04id100" value="" title="43. REVENUE DESCRIPTION, Line 1"  name="ub04Block_99"/>
1078 <input type="text"   maxlength="24"  id="ub04id101" value="" title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 1"  name="ub04Block_100"/>
1079 <input type="text"   maxlength="10"  id="ub04id102" value=""  title="45. SERVICE DATE, Line 1"  name="ub04Block_101"/>
1080 <input type="text"   maxlength="7"  id="ub04id103" value=""  title="46. SERVICE UNITS, Line 1"  name="ub04Block_102"/>
1081 <input type="text"   maxlength="9"  id="ub04id104" value=""  title="47. TOTAL CHARGES, Line 1"  name="ub04Block_103"/>
1082 <input type="text"   maxlength="9"  id="ub04id105" value=""  title="48. NON-COVERED CHARGES, Line 1"  name="ub04Block_104"/>
1083 <input type="text" disabled  maxlength="2"  id="ub04id106" value=""  title="49. RESERVED, Line 1"  name="ub04Block_105"/>
1084 <input type="text" class="revcode" maxlength="4"  id="ub04id107" value=""  title="42. REVENUE CODE, Line 2"  name="ub04Block_106"/>
1085 <input type="text"   maxlength="25"  id="ub04id108" value=""  title="43. REVENUE DESCRIPTION, Line 2"  name="ub04Block_107"/>
1086 <input type="text"   maxlength="24"  id="ub04id109" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 2"  name="ub04Block_108"/>
1087 <input type="text"   maxlength="10"  id="ub04id110" value=""  title="45. SERVICE DATE, Line 2"  name="ub04Block_109"/>
1088 <input type="text"   maxlength="7"  id="ub04id111" value=""  title="46. SERVICE UNITS, Line 2"  name="ub04Block_110"/>
1089 <input type="text"   maxlength="9"  id="ub04id112" value=""  title="47. TOTAL CHARGES, Line 2"  name="ub04Block_111"/>
1090 <input type="text"   maxlength="9"  id="ub04id113" value=""  title="48. NON-COVERED CHARGES, Line 2"  name="ub04Block_112"/>
1091 <input type="text" disabled  maxlength="2"  id="ub04id114" value=""  title="49. RESERVED, Line 2"  name="ub04Block_113"/>
1092 <input type="text"   maxlength="4"  id="ub04id115" value=""  title="42. REVENUE CODE, Line 3"  name="ub04Block_114"/>
1093 <input type="text"   maxlength="25"  id="ub04id116" value=""  title="43. REVENUE DESCRIPTION, Line 3"  name="ub04Block_115"/>
1094 <input type="text"   maxlength="24"  id="ub04id117" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 3"  name="ub04Block_116"/>
1095 <input type="text" class="revcode" maxlength="10"  id="ub04id118" value=""  title="45. SERVICE DATE, Line 3"  name="ub04Block_117"/>
1096 <input type="text"   maxlength="7"  id="ub04id119" value=""  title="46. SERVICE UNITS, Line 3"  name="ub04Block_118"/>
1097 <input type="text"   maxlength="9"  id="ub04id120" value=""  title="47. TOTAL CHARGES, Line 3"  name="ub04Block_119"/>
1098 <input type="text"   maxlength="9"  id="ub04id121" value=""  title="48. NON-COVERED CHARGES, Line 3"  name="ub04Block_120"/>
1099 <input type="text"  disabled maxlength="2"  id="ub04id122" value=""  title="49. RESERVED, Line 3"  name="ub04Block_121"/>
1100 <input type="text"   maxlength="4"  id="ub04id123" value=""  title="42. REVENUE CODE, Line 4"  name="ub04Block_122"/>
1101 <input type="text"   maxlength="25"  id="ub04id124" value=""  title="43. REVENUE DESCRIPTION, Line 4"  name="ub04Block_123"/>
1102 <input type="text"   maxlength="24"  id="ub04id125" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 4"  name="ub04Block_124"/>
1103 <input type="text"   maxlength="10"  id="ub04id126" value=""  title="45. SERVICE DATE, Line 4"  name="ub04Block_125"/>
1104 <input type="text"   maxlength="7"  id="ub04id127" value=""  title="46. SERVICE UNITS, Line 4"  name="ub04Block_126"/>
1105 <input type="text"   maxlength="9"  id="ub04id128" value=""  title="47. TOTAL CHARGES, Line 4"  name="ub04Block_127"/>
1106 <input type="text"   maxlength="9"  id="ub04id129" value=""  title="48. NON-COVERED CHARGES, Line 4"  name="ub04Block_128"/>
1107 <input type="text" disabled  maxlength="2"  id="ub04id130" value=""  title="49. RESERVED, Line 4"  name="ub04Block_129"/>
1108 <input type="text"   maxlength="4"  id="ub04id131" value=""  title="42. REVENUE CODE, Line 5"  name="ub04Block_130"/>
1109 <input type="text"   maxlength="25"  id="ub04id132" value=""  title="43. REVENUE DESCRIPTION, Line 5"  name="ub04Block_131"/>
1110 <input type="text"   maxlength="24"  id="ub04id133" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 5"  name="ub04Block_132"/>
1111 <input type="text"   maxlength="10"  id="ub04id134" value=""  title="45. SERVICE DATE, Line 5"  name="ub04Block_133"/>
1112 <input type="text"   maxlength="7"  id="ub04id135" value=""  title="46. SERVICE UNITS, Line 5"  name="ub04Block_134"/>
1113 <input type="text"   maxlength="9"  id="ub04id136" value=""  title="47. TOTAL CHARGES, Line 5"  name="ub04Block_135"/>
1114 <input type="text"   maxlength="9"  id="ub04id137" value=""  title="48. NON-COVERED CHARGES, Line 5"  name="ub04Block_136"/>
1115 <input type="text" disabled  maxlength="2"  id="ub04id138" value=""  title="49. RESERVED, Line 5"  name="ub04Block_137"/>
1116 <input type="text"   maxlength="4"  id="ub04id139" value=""  title="42. REVENUE CODE, Line 6"  name="ub04Block_138"/>
1117 <input type="text"   maxlength="25"  id="ub04id140" value=""  title="43. REVENUE DESCRIPTION, Line 6"  name="ub04Block_139"/>
1118 <input type="text"   maxlength="24"  id="ub04id141" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 6"  name="ub04Block_140"/>
1119 <input type="text"   maxlength="10"  id="ub04id142" value=""  title="45. SERVICE DATE, Line 6"  name="ub04Block_141"/>
1120 <input type="text"   maxlength="7"  id="ub04id143" value=""  title="46. SERVICE UNITS, Line 6"  name="ub04Block_142"/>
1121 <input type="text"   maxlength="9"  id="ub04id144" value=""  title="47. TOTAL CHARGES, Line 6"  name="ub04Block_143"/>
1122 <input type="text"   maxlength="9"  id="ub04id145" value=""  title="48. NON-COVERED CHARGES, Line 6"  name="ub04Block_144"/>
1123 <input type="text" disabled  maxlength="2"  id="ub04id146" value=""  title="49. RESERVED, Line 6"  name="ub04Block_145"/>
1124 <input type="text"   maxlength="4"  id="ub04id147" value=""  title="42. REVENUE CODE, Line 7"  name="ub04Block_146"/>
1125 <input type="text"   maxlength="25"  id="ub04id148" value=""  title="43. REVENUE DESCRIPTION, Line 7"  name="ub04Block_147"/>
1126 <input type="text"   maxlength="24"  id="ub04id149" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 7"  name="ub04Block_148"/>
1127 <input type="text"   maxlength="10"  id="ub04id150" value=""  title="45. SERVICE DATE, Line 7"  name="ub04Block_149"/>
1128 <input type="text"   maxlength="7"  id="ub04id151" value=""  title="46. SERVICE UNITS, Line 7"  name="ub04Block_150"/>
1129 <input type="text"   maxlength="9"  id="ub04id152" value=""  title="47. TOTAL CHARGES, Line 7"  name="ub04Block_151"/>
1130 <input type="text"   maxlength="9"  id="ub04id153" value=""  title="48. NON-COVERED CHARGES, Line 7"  name="ub04Block_152"/>
1131 <input type="text" disabled  maxlength="2"  id="ub04id154" value=""  title="49. RESERVED, Line 7"  name="ub04Block_153"/>
1132 <input type="text"   maxlength="4"  id="ub04id155" value=""  title="42. REVENUE CODE, Line 8"  name="ub04Block_154"/>
1133 <input type="text"   maxlength="25"  id="ub04id156" value=""  title="43. REVENUE DESCRIPTION, Line 8"  name="ub04Block_155"/>
1134 <input type="text"   maxlength="24"  id="ub04id157" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 8"  name="ub04Block_156"/>
1135 <input type="text"   maxlength="10"  id="ub04id158" value=""  title="45. SERVICE DATE, Line 8"  name="ub04Block_157"/>
1136 <input type="text"   maxlength="7"  id="ub04id159" value=""  title="46. SERVICE UNITS, Line 8"  name="ub04Block_158"/>
1137 <input type="text"   maxlength="9"  id="ub04id160" value=""  title="47. TOTAL CHARGES, Line 8"  name="ub04Block_159"/>
1138 <input type="text"   maxlength="9"  id="ub04id161" value=""  title="48. NON-COVERED CHARGES, Line 8"  name="ub04Block_160"/>
1139 <input type="text"   maxlength="2"  id="ub04id162" value=""  title="49. RESERVED, Line 8"  name="ub04Block_161"/>
1140 <input type="text"   maxlength="4"  id="ub04id163" value=""  title="42. REVENUE CODE, Line 9"  name="ub04Block_162"/>
1141 <input type="text"   maxlength="25"  id="ub04id164" value=""  title="43. REVENUE DESCRIPTION, Line 9"  name="ub04Block_163"/>
1142 <input type="text"   maxlength="24"  id="ub04id165" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 9"  name="ub04Block_164"/>
1143 <input type="text"   maxlength="10"  id="ub04id166" value=""  title="45. SERVICE DATE, Line 9"  name="ub04Block_165"/>
1144 <input type="text"   maxlength="7"  id="ub04id167" value=""  title="46. SERVICE UNITS, Line 9"  name="ub04Block_166"/>
1145 <input type="text"   maxlength="9"  id="ub04id168" value=""  title="47. TOTAL CHARGES, Line 9"  name="ub04Block_167"/>
1146 <input type="text"   maxlength="9"  id="ub04id169" value=""  title="48. NON-COVERED CHARGES, Line 9"  name="ub04Block_168"/>
1147 <input type="text" disabled  maxlength="2"  id="ub04id170" value=""  title="49. RESERVED, Line 9"  name="ub04Block_169"/>
1148 <input type="text"   maxlength="4"  id="ub04id171" value=""  title="42. REVENUE CODE, Line 10"  name="ub04Block_170"/>
1149 <input type="text"   maxlength="25"  id="ub04id172" value=""  title="43. REVENUE DESCRIPTION, Line 10"  name="ub04Block_171"/>
1150 <input type="text"   maxlength="24"  id="ub04id173" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 10"  name="ub04Block_172"/>
1151 <input type="text"   maxlength="10"  id="ub04id174" value=""  title="45. SERVICE DATE, Line 10"  name="ub04Block_173"/>
1152 <input type="text"   maxlength="7"  id="ub04id175" value=""  title="46. SERVICE UNITS, Line 10"  name="ub04Block_174"/>
1153 <input type="text"   maxlength="9"  id="ub04id176" value=""  title="47. TOTAL CHARGES, Line 10"  name="ub04Block_175"/>
1154 <input type="text"   maxlength="9"  id="ub04id177" value=""  title="48. NON-COVERED CHARGES, Line 10"  name="ub04Block_176"/>
1155 <input type="text"  disabled maxlength="2"  id="ub04id178" value=""  title="49. RESERVED, Line 10"  name="ub04Block_177"/>
1156 <input type="text"   maxlength="4"  id="ub04id179" value=""  title="42. REVENUE CODE, Line 11"  name="ub04Block_178"/>
1157 <input type="text"   maxlength="25"  id="ub04id180" value=""  title="43. REVENUE DESCRIPTION, Line 11"  name="ub04Block_179"/>
1158 <input type="text"   maxlength="24"  id="ub04id181" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 11"  name="ub04Block_180"/>
1159 <input type="text"   maxlength="10"  id="ub04id182" value=""  title="45. SERVICE DATE, Line 11"  name="ub04Block_181"/>
1160 <input type="text"   maxlength="7"  id="ub04id183" value=""  title="46. SERVICE UNITS, Line 11"  name="ub04Block_182"/>
1161 <input type="text"   maxlength="9"  id="ub04id184" value=""  title="47. TOTAL CHARGES, Line 11"  name="ub04Block_183"/>
1162 <input type="text"   maxlength="9"  id="ub04id185" value=""  title="48. NON-COVERED CHARGES, Line 11"  name="ub04Block_184"/>
1163 <input type="text" disabled  maxlength="2"  id="ub04id186" value=""  title="49. RESERVED, Line 11"  name="ub04Block_185"/>
1164 <input type="text"   maxlength="4"  id="ub04id187" value=""  title="42. REVENUE CODE, Line 12"  name="ub04Block_186"/>
1165 <input type="text"   maxlength="25"  id="ub04id188" value=""  title="43. REVENUE DESCRIPTION, Line 12"  name="ub04Block_187"/>
1166 <input type="text"   maxlength="24"  id="ub04id189" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 12"  name="ub04Block_188"/>
1167 <input type="text"   maxlength="10"  id="ub04id190" value=""  title="45. SERVICE DATE, Line 12"  name="ub04Block_189"/>
1168 <input type="text"   maxlength="7"  id="ub04id191" value=""  title="46. SERVICE UNITS, Line 12"  name="ub04Block_190"/>
1169 <input type="text"   maxlength="9"  id="ub04id192" value=""  title="47. TOTAL CHARGES, Line 12"  name="ub04Block_191"/>
1170 <input type="text"   maxlength="9"  id="ub04id193" value=""  title="48. NON-COVERED CHARGES, Line 12"  name="ub04Block_192"/>
1171 <input type="text" disabled  maxlength="2"  id="ub04id194" value=""  title="49. RESERVED, Line 12"  name="ub04Block_193"/>
1172 <input type="text"   maxlength="4"  id="ub04id195" value=""  title="42. REVENUE CODE, Line 13"  name="ub04Block_194"/>
1173 <input type="text"   maxlength="25"  id="ub04id196" value=""  title="43. REVENUE DESCRIPTION, Line 13"  name="ub04Block_195"/>
1174 <input type="text"   maxlength="24"  id="ub04id197" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 13"  name="ub04Block_196"/>
1175 <input type="text"   maxlength="10"  id="ub04id198" value=""  title="45. SERVICE DATE, Line 13"  name="ub04Block_197"/>
1176 <input type="text"   maxlength="7"  id="ub04id199" value=""  title="46. SERVICE UNITS, Line 13"  name="ub04Block_198"/>
1177 <input type="text"   maxlength="9"  id="ub04id200" value=""  title="47. TOTAL CHARGES, Line 13"  name="ub04Block_199"/>
1178 <input type="text"   maxlength="9"  id="ub04id201" value=""  title="48. NON-COVERED CHARGES, Line 13"  name="ub04Block_200"/>
1179 <input type="text" disabled  maxlength="2"  id="ub04id202" value=""  title="49. RESERVED, Line 13"  name="ub04Block_201"/>
1180 <input type="text"   maxlength="4"  id="ub04id203" value=""  title="42. REVENUE CODE, Line 14"  name="ub04Block_202"/>
1181 <input type="text"   maxlength="25"  id="ub04id204" value=""  title="43. REVENUE DESCRIPTION, Line 14"  name="ub04Block_203"/>
1182 <input type="text"   maxlength="24"  id="ub04id205" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 14"  name="ub04Block_204"/>
1183 <input type="text"   maxlength="10"  id="ub04id206" value=""  title="45. SERVICE DATE, Line 14"  name="ub04Block_205"/>
1184 <input type="text"   maxlength="7"  id="ub04id207" value=""  title="46. SERVICE UNITS, Line 14"  name="ub04Block_206"/>
1185 <input type="text"   maxlength="9"  id="ub04id208" value=""  title="47. TOTAL CHARGES, Line 14"  name="ub04Block_207"/>
1186 <input type="text"   maxlength="9"  id="ub04id209" value=""  title="48. NON-COVERED CHARGES, Line 14"  name="ub04Block_208"/>
1187 <input type="text"  disabled maxlength="2"  id="ub04id210" value=""  title="49. RESERVED, Line 14"  name="ub04Block_209"/>
1188 <input type="text"   maxlength="4"  id="ub04id211" value=""  title="42. REVENUE CODE, Line 15"  name="ub04Block_210"/>
1189 <input type="text"   maxlength="25"  id="ub04id212" value=""  title="43. REVENUE DESCRIPTION, Line 15"  name="ub04Block_211"/>
1190 <input type="text"   maxlength="24"  id="ub04id213" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 15"  name="ub04Block_212"/>
1191 <input type="text"   maxlength="10"  id="ub04id214" value=""  title="45. SERVICE DATE, Line 15"  name="ub04Block_213"/>
1192 <input type="text"   maxlength="7"  id="ub04id215" value=""  title="46. SERVICE UNITS, Line 15"  name="ub04Block_214"/>
1193 <input type="text"   maxlength="9"  id="ub04id216" value=""  title="47. TOTAL CHARGES, Line 15"  name="ub04Block_215"/>
1194 <input type="text"   maxlength="9"  id="ub04id217" value=""  title="48. NON-COVERED CHARGES, Line 15"  name="ub04Block_216"/>
1195 <input type="text" disabled  maxlength="2"  id="ub04id218" value=""  title="49. RESERVED, Line 15"  name="ub04Block_217"/>
1196 <input type="text"   maxlength="4"  id="ub04id219" value=""  title="42. REVENUE CODE, Line 16"  name="ub04Block_218"/>
1197 <input type="text"   maxlength="25"  id="ub04id220" value=""  title="43. REVENUE DESCRIPTION, Line 16"  name="ub04Block_219"/>
1198 <input type="text"   maxlength="24"  id="ub04id221" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 16"  name="ub04Block_220"/>
1199 <input type="text"   maxlength="10"  id="ub04id222" value=""  title="45. SERVICE DATE, Line 16"  name="ub04Block_221"/>
1200 <input type="text"   maxlength="7"  id="ub04id223" value=""  title="46. SERVICE UNITS, Line 16"  name="ub04Block_222"/>
1201 <input type="text"   maxlength="9"  id="ub04id224" value=""  title="47. TOTAL CHARGES, Line 16"  name="ub04Block_223"/>
1202 <input type="text"   maxlength="9"  id="ub04id225" value=""  title="48. NON-COVERED CHARGES, Line 16"  name="ub04Block_224"/>
1203 <input type="text" disabled  maxlength="2"  id="ub04id226" value=""  title="49. RESERVED, Line 16"  name="ub04Block_225"/>
1204 <input type="text"   maxlength="4"  id="ub04id227" value=""  title="42. REVENUE CODE, Line 17"  name="ub04Block_226"/>
1205 <input type="text"   maxlength="25"  id="ub04id228" value=""  title="43. REVENUE DESCRIPTION, Line 17"  name="ub04Block_227"/>
1206 <input type="text"   maxlength="24"  id="ub04id229" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 17"  name="ub04Block_228"/>
1207 <input type="text"   maxlength="10"  id="ub04id230" value=""  title="45. SERVICE DATE, Line 17"  name="ub04Block_229"/>
1208 <input type="text"   maxlength="7"  id="ub04id231" value=""  title="46. SERVICE UNITS, Line 17"  name="ub04Block_230"/>
1209 <input type="text"   maxlength="9"  id="ub04id232" value=""  title="47. TOTAL CHARGES, Line 17"  name="ub04Block_231"/>
1210 <input type="text"   maxlength="9"  id="ub04id233" value=""  title="48. NON-COVERED CHARGES, Line 17"  name="ub04Block_232"/>
1211 <input type="text" disabled  maxlength="2"  id="ub04id234" value=""  title="49. RESERVED, Line 17"  name="ub04Block_233"/>
1212 <input type="text"   maxlength="4"  id="ub04id235" value=""  title="42. REVENUE CODE, Line 18"  name="ub04Block_234"/>
1213 <input type="text"   maxlength="25"  id="ub04id236" value=""  title="43. REVENUE DESCRIPTION, Line 18"  name="ub04Block_235"/>
1214 <input type="text"   maxlength="24"  id="ub04id237" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 18"  name="ub04Block_236"/>
1215 <input type="text"   maxlength="10"  id="ub04id238" value=""  title="45. SERVICE DATE, Line 18"  name="ub04Block_237"/>
1216 <input type="text"   maxlength="7"  id="ub04id239" value=""  title="46. SERVICE UNITS, Line 18"  name="ub04Block_238"/>
1217 <input type="text"   maxlength="9"  id="ub04id240" value=""  title="47. TOTAL CHARGES, Line 18"  name="ub04Block_239"/>
1218 <input type="text"   maxlength="9"  id="ub04id241" value=""  title="48. NON-COVERED CHARGES, Line 18"  name="ub04Block_240"/>
1219 <input type="text" disabled  maxlength="2"  id="ub04id242" value=""  title="49. RESERVED, Line 18"  name="ub04Block_241"/>
1220 <input type="text"   maxlength="4"  id="ub04id243" value=""  title="42. REVENUE CODE, Line 19"  name="ub04Block_242"/>
1221 <input type="text"   maxlength="25"  id="ub04id244" value=""  title="43. REVENUE DESCRIPTION, Line 19"  name="ub04Block_243"/>
1222 <input type="text"   maxlength="24"  id="ub04id245" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 19"  name="ub04Block_244"/>
1223 <input type="text"   maxlength="10"  id="ub04id246" value=""  title="45. SERVICE DATE, Line 19"  name="ub04Block_245"/>
1224 <input type="text"   maxlength="7"  id="ub04id247" value=""  title="46. SERVICE UNITS, Line 19"  name="ub04Block_246"/>
1225 <input type="text"   maxlength="9"  id="ub04id248" value=""  title="47. TOTAL CHARGES, Line 19"  name="ub04Block_247"/>
1226 <input type="text"   maxlength="9"  id="ub04id249" value=""  title="48. NON-COVERED CHARGES, Line 19"  name="ub04Block_248"/>
1227 <input type="text" disabled  maxlength="2"  id="ub04id250" value=""  title="49. RESERVED, Line 19"  name="ub04Block_249"/>
1228 <input type="text"   maxlength="4"  id="ub04id251" value=""  title="42. REVENUE CODE, Line 20"  name="ub04Block_250"/>
1229 <input type="text"   maxlength="25"  id="ub04id252" value=""  title="43. REVENUE DESCRIPTION, Line 20"  name="ub04Block_251"/>
1230 <input type="text"   maxlength="24"  id="ub04id253" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 20"  name="ub04Block_252"/>
1231 <input type="text"   maxlength="10"  id="ub04id254" value=""  title="45. SERVICE DATE, Line 20"  name="ub04Block_253"/>
1232 <input type="text"   maxlength="7"  id="ub04id255" value=""  title="46. SERVICE UNITS, Line 20"  name="ub04Block_254"/>
1233 <input type="text"   maxlength="9"  id="ub04id256" value=""  title="47. TOTAL CHARGES, Line 20"  name="ub04Block_255"/>
1234 <input type="text"   maxlength="9"  id="ub04id257" value=""  title="48. NON-COVERED CHARGES, Line 20"  name="ub04Block_256"/>
1235 <input type="text" disabled  maxlength="2"  id="ub04id258" value=""  title="49. RESERVED, Line 20"  name="ub04Block_257"/>
1236 <input type="text"   maxlength="4"  id="ub04id259" value=""  title="42. REVENUE CODE, Line 21"  name="ub04Block_258"/>
1237 <input type="text"   maxlength="25"  id="ub04id260" value=""  title="43. REVENUE DESCRIPTION, Line 21"  name="ub04Block_259"/>
1238 <input type="text"   maxlength="24"  id="ub04id261" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 21"  name="ub04Block_260"/>
1239 <input type="text"   maxlength="10"  id="ub04id262" value=""  title="45. SERVICE DATE, Line 21"  name="ub04Block_261"/>
1240 <input type="text"   maxlength="7"  id="ub04id263" value=""  title="46. SERVICE UNITS, Line 21"  name="ub04Block_262"/>
1241 <input type="text"   maxlength="9"  id="ub04id264" value=""  title="47. TOTAL CHARGES, Line 21"  name="ub04Block_263"/>
1242 <input type="text"   maxlength="9"  id="ub04id265" value=""  title="48. NON-COVERED CHARGES, Line 21"  name="ub04Block_264"/>
1243 <input type="text" disabled  maxlength="2"  id="ub04id266" value=""  title="49. RESERVED, Line 21"  name="ub04Block_265"/>
1244 <input type="text"   maxlength="4"  id="ub04id267" value=""  title="42. REVENUE CODE, Line 22"  name="ub04Block_266"/>
1245 <input type="text"   maxlength="25"  id="ub04id268" value=""  title="43. REVENUE DESCRIPTION, Line 22"  name="ub04Block_267"/>
1246 <input type="text"   maxlength="24"  id="ub04id269" value=""  title="44. HCPCS/ACCOMMODATION RATES/HIPPS RATE CODES, Line 22"  name="ub04Block_268"/>
1247 <input type="text"   maxlength="10"  id="ub04id270" value=""  title="45. SERVICE DATE, Line 22"  name="ub04Block_269"/>
1248 <input type="text"   maxlength="7"  id="ub04id271" value=""  title="46. SERVICE UNITS, Line 22"  name="ub04Block_270"/>
1249 <input type="text"   maxlength="9"  id="ub04id272" value=""  title="47. TOTAL CHARGES, Line 22"  name="ub04Block_271"/>
1250 <input type="text"   maxlength="9"  id="ub04id273" value=""  title="48. NON-COVERED CHARGES, Line 22"  name="ub04Block_272"/>
1251 <input type="text" disabled  maxlength="2"  id="ub04id274" value=""  title="49. RESERVED, Line 22"  name="ub04Block_273"/>
1252 <input type="text"    id="ub04id275" value=""  title="42. REVENUE CODE, Line 23"  name="ub04Block_274"/>
1253 <input type="text"   maxlength="3"  id="ub04id276" value=""  title="43. CLAIM PAGE NUMBER"  name="ub04Block_275"/>
1254 <input type="text"   maxlength="3"  id="ub04id277" value=""  title="43. TOTAL NUMBER OF CLAIM PAGES"  name="ub04Block_276"/>
1255 <input type="text"    id="ub04id278" value=""  title="45. CREATION DATE, Line 23"  name="ub04Block_277"/>
1256 <input type="text"    id="ub04id279" value=""  title="47. TOTAL OF TOTAL CHARGES, Line 23"  name="ub04Block_278"/>
1257 <input type="text"    id="ub04id280" value=""  title="48. TOTAL OF NON-COVERED CHARGES, Line 23"  name="ub04Block_279"/>
1258 <input type="text" disabled id="ub04id281" value=""  title="49. RESERVED, Line 23"  name="ub04Block_280"/>
1259 <input type="text"   maxlength="10"  id="ub04id282" value="" title="56. NATIONAL PROVIDER IDENTIFIER - BILLING PROVIDER"  name="ub04Block_299"/>
1260 <input type="text"   maxlength="23"  id="ub04id283" value="" title="50a. PRIMARY PAYER NAME"  name="ub04Block_281"/>
1261 <input type="text"   maxlength="15"  id="ub04id284" value="" title="51a. PRIMARY PAYER HEALTH PLAN ID"  name="ub04Block_282"/>
1262 <input type="text"   maxlength="1"  id="ub04id285" value="" title="52a. RELEASE OF INFORMATION CERTIFICATION INDICATOR, PRIMARY PAYER"  name="ub04Block_283"/>
1263 <input type="text"   maxlength="1"  id="ub04id286" value="" title="53a. ASSIGNMENT OF BENEFITS CERTIFICATION INDICATOR, PRIMARY PAYER"  name="ub04Block_284"/>
1264 <input type="text"   maxlength="10"  id="ub04id287" value="" title="54a. PRIMARY PAYER PRIOR PAYMENTS"  name="ub04Block_285"/>
1265 <input type="text"   maxlength="10"  id="ub04id288" value="" title="55a. PRIMARY PAYER ESTIMATED AMOUNT DUE"  name="ub04Block_286"/>
1266 <input type="text"    id="ub04id289" value=""  title="57a. OTHER (BILLING) PROVIDER IDENTIFIER"  name="ub04Block_300"/>
1267 <input type="text"   maxlength="23"  id="ub04id290" value="" title="50b. SECONDARY PAYER NAME"  name="ub04Block_287"/>
1268 <input type="text"   maxlength="15"  id="ub04id291" value="" title="51b. SECONDARY PAYER HEALTH PLAN ID"  name="ub04Block_288"/>
1269 <input type="text"   maxlength="1"  id="ub04id292" value="" title="52b. RELEASE OF INFORMATION CERTIFICATION INDICATOR, SECONDARY PAYER"  name="ub04Block_289"/>
1270 <input type="text"   maxlength="1"  id="ub04id293" value="" title="53b. ASSIGNMENT OF BENEFITS CERTIFICATION INDICATOR, SECONDARY PAYER"  name="ub04Block_290"/>
1271 <input type="text"   maxlength="10"  id="ub04id294" value="" title="54b. SECONDARY PAYER PRIOR PAYMENTS"  name="ub04Block_291"/>
1272 <input type="text"   maxlength="10"  id="ub04id295" value="" title="55b. SECONDARY PAYER ESTIMATED AMOUNT DUE"  name="ub04Block_292"/>
1273 <input type="text"    id="ub04id296" value="" title="57b. OTHER (BILLING) PROVIDER IDENTIFIER"  name="ub04Block_301"/>
1274 <input type="text"   maxlength="23"  id="ub04id297" value="" title="50c. TERTIARY PAYER NAME"  name="ub04Block_293"/>
1275 <input type="text"   maxlength="15"  id="ub04id298" value="" title="51c. TERTIARY PAYER HEALTH PLAN ID"  name="ub04Block_294"/>
1276 <input type="text"   maxlength="1"  id="ub04id299" value="" title="52c.RELEASE OF INFORMATION CERTIFICATION INDICATOR, TERTIARY PAYER"  name="ub04Block_295"/>
1277 <input type="text"   maxlength="1"  id="ub04id300" value="" title="53c. ASSIGNMENT OF BENEFITS CERTIFICATION INDICATOR, TERTIARY PAYER"  name="ub04Block_296"/>
1278 <input type="text"   maxlength="10"  id="ub04id301" value="" title="54c. TERTIARY PAYER PRIOR PAYMENTS"  name="ub04Block_297"/>
1279 <input type="text"   maxlength="10"  id="ub04id302" value="" title="55c. TERTIARY PAYER ESTIMATED AMOUNT DUE"  name="ub04Block_298"/>
1280 <input type="text"    id="ub04id303" value="" title="57c. OTHER (BILLING) PROVIDER IDENTIFIER"  name="ub04Block_302"/>
1281 <input type="text"   maxlength="25"  id="ub04id304" value="" title="58a. INSURED'S NAME - PRIMARY PLAN"  name="ub04Block_303"/>
1282 <input type="text"   maxlength="2"  id="ub04id305" value="" title="59a. PATIENT'S RELATIONSHIP TO INSURED - PRIMARY PLAN"  name="ub04Block_304"/>
1283 <input type="text"   maxlength="20"  id="ub04id306" value="" title="60a. INSURED'S UNIQUE IDENTIFIER - PRIMARY PLAN"  name="ub04Block_305"/>
1284 <input type="text"   maxlength="14"  id="ub04id307" value="" title="61a. INSURED'S GROUP NAME - PRIMARY PLAN"  name="ub04Block_306"/>
1285 <input type="text"   maxlength="17"  id="ub04id308" value="" title="62a. INSURANCE GROUP NUMBER - PRIMARY PLAN"  name="ub04Block_307"/>
1286 <input type="text"   maxlength="25"  id="ub04id309" value="" title="58b. INSURED'S NAME - SECONDARY PLAN"  name="ub04Block_308"/>
1287 <input type="text"   maxlength="2"  id="ub04id310" value="" title="59b. PATIENT'S RELATIONSHIP TO INSURED - SECONDARY PLAN"  name="ub04Block_309"/>
1288 <input type="text"   maxlength="20"  id="ub04id311" value="" title="60b. INSURED'S UNIQUE IDENTIFIER - SECONDARY PLAN"  name="ub04Block_310"/>
1289 <input type="text"   maxlength="14"  id="ub04id312" value="" title="61b. INSURED'S GROUP NAME - SECONDARY PLAN"  name="ub04Block_311"/>
1290 <input type="text"   maxlength="17"  id="ub04id313" value="" title="62b. INSURANCE GROUP NUMBER - SECONDARY PLAN"  name="ub04Block_312"/>
1291 <input type="text"   maxlength="25"  id="ub04id314" value="" title="58c. INSURED'S NAME - TERTIARY PLAN"  name="ub04Block_313"/>
1292 <input type="text"   maxlength="2"  id="ub04id315" value="" title="59c. PATIENT'S RELATIONSHIP TO INSURED - TERTIARY PLAN"  name="ub04Block_314"/>
1293 <input type="text"   maxlength="20"  id="ub04id316" value="" title="60c. INSURED'S UNIQUE IDENTIFIER - TERTIARY PLAN"  name="ub04Block_315"/>
1294 <input type="text"   maxlength="14"  id="ub04id317" value="" title="61c. INSURED'S GROUP NAME - TERTIARY PLAN"  name="ub04Block_316"/>
1295 <input type="text"   maxlength="17"  id="ub04id318" value="" title="62c. INSURANCE GROUP NUMBER - TERTIARY PLAN"  name="ub04Block_317"/>
1296 <input type="text"   maxlength="30"  id="ub04id319" value="" title="63a. TREATMENT AUTHORIZATION CODES - PRIMARY PLAN"  name="ub04Block_318"/>
1297 <input type="text"   maxlength="26"  id="ub04id320" value="" title="64a. DOCUMENT CONTROL NUMBER (DCN) - PRIMARY PLAN"  name="ub04Block_319"/>
1298 <input type="text"   maxlength="25"  id="ub04id321" value="" title="65a. INSURED'S EMPLOYER NAME - PRIMARY PLAN"  name="ub04Block_320"/>
1299 <input type="text"   maxlength="30"  id="ub04id322" value="" title="63b. TREATMENT AUTHORIZATION CODES - SECONDARY PLAN"  name="ub04Block_321"/>
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1301 <input type="text"   maxlength="25"  id="ub04id324" value="" title="65b. INSURED'S EMPLOYER NAME - SECONDARY PLAN"  name="ub04Block_323"/>
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1303 <input type="text"   maxlength="26"  id="ub04id326" value="" title="64c. DOCUMENT CONTROL NUMBER (DCN) - TERTIARY PLAN"  name="ub04Block_325"/>
1304 <input type="text"   maxlength="25"  id="ub04id327" value="" title="65c. INSURED'S EMPLOYER NAME - TERTIARY PLAN"  name="ub04Block_326"/>
1305 <input type="text"   maxlength="7"  id="ub04id328" value="" title="67. PRINCIPAL DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_328"/>
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1307 <input type="text"   maxlength="7"  id="ub04id330" value="" title="67A. OTHER DIAGNOSIS CODE AND POA INDICATOR"  name="ub04Block_330"/>
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1324 <input type="text"   maxlength="1"  id="ub04id347" value="" title="66. DIAGNOSIS AND PROCEDURE CODE QUALIFIER (ICD VERSION INDICATOR)"  name="ub04Block_327"/>
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1345 <input type="text"   maxlength="7"  id="ub04id368" value="" title="70a. PATIENT'S REASON FOR VISIT"  name="ub04Block_367"/>
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