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
  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
• 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.
• 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