The Patient Data Sheet Detail includes four sections with the following information.
Patient Information
- Name
- Medical Record Number
- SSN
- Birth Date
- Language
- Sex
- Address
- Referring Physician
- Secondary Address
- Ethnicity
- Sexual Orientation
Note: This field displays as a masked 10-character string (##########) when in Universal Preferences the Person Demographics-Show Gender Identity/Sexual Orientation in EHR only is set to True.
- Preferred Pronoun
- Home Phone
- Day Phone
- EMail Address
- Primary Care Provider
- Race
- Gender Identity
Note: This field displays as a masked 10-character string (##########) when in Universal Preferences the Person Demographics-Show Gender Identity/Sexual Orientation in EHR only is set to True.
- Marital Status
- Student Status
- Smoker (Y/N)
- Veteran (Y/N)
- Emergency Contact Name
- Contact Home Phone
- Secondary 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
- Day Phone
- EMail Address
- Marital Status
- Student Status
- Smoker (Y/N)
- Veteran (Y/N)
- Primary Care Provider
- Secondary Home Phone
- Relationship to Patient
Primary Insurance
- Insurance Name
- Policy Number
- Name of Insured
- Group Number
- Insurance Address
- Phone
- Co-Pay Amount
- Deductible Amount
- Relationship to Patient
- Effective Date
- Expiration Date
Secondary Insurance
- Insurance Name
- Policy Number
- Name of Insured
- Group Number
- Insurance Address
- Phone
- Co-Pay Amount
- Deductible Amount
- Relationship to Patient
- Effective Date
- Expiration Date
