NextGen Knowledge Center

Patient Data Sheet - Data Fields

The Patient Data Sheet includes four sections with the following information.

Patient Information

  • Name
  • Medical Record Number
  • SSN
  • Birth Date
  • Language
  • Sex
  • Address
  • Secondary Address
  • Ethnicity
  • Home Phone
  • Secondary Home Phone
  • Race
  • Sexual Orientation
  • Preferred Pronoun
  • Gender Identity
  • Primary Care Physician
  • Referring Physician
  • Contact Name
  • Contact Home Phone
  • Primary Employer (Name, Address, Phone)
  • Secondary Employer (Name, Address, Phone)

Responsible Party Information

  • Name
  • SSN
  • Birth Date
  • Language
  • Sex
  • Address
  • Secondary Address
  • Home Phone
  • Secondary Home Phone
  • Relationship to Patient

Primary Insurance

  • Insurance Name
  • Policy Number
  • Name of Insured
  • Group Number
  • Insurance Address
  • Co-Pay Amount
  • Deductible Amount
  • Relationship to Patient
  • Effective Date
  • Expiration Date

Secondary Insurance

  • Insurance Name
  • Policy Number
  • Name of Insured
  • SSN
  • Birth Date
  • Group Number
  • Insurance Address
  • Co-Pay Amount
  • Deductible Amount
  • Relationship to Patient
  • Effective Date
  • Expiration Date