Template  IN2 - Insurance Additional Information

Insured's Employee ID

Insured's Social Security Number

Insured's Employer's Name and ID

Employer Information Data

Mail Claim Party

Medicare Health Ins Card Number

Medicaid Case Name

Medicaid Case Number

Military Sponsor Name

Military ID Number

Dependent Of Military Recipient

Military Organization

Military Station

Military Service

Military Rank/Grade

Military Status

Military Retire Date

Military Non-Avail Cert On File

Baby Coverage

Combine Baby Bill

Blood Deductible

Special Coverage Approval Name

Special Coverage Approval Title

Non-Covered Insurance Code

Payor ID

Payor Subscriber ID

Eligibility Source

Room Coverage Type/Amount

Policy Type/Amount

Daily Deductible

Living Dependency

Ambulatory Status

Citizenship

Primary Language

Living Arrangement

Publicity Code

Protection Indicator

Student Indicator

Religion

Mother's Maiden Name

Nationality

Ethnic Group

Marital Status

Insured's Employment Start Date

Employment Stop Date

Job Title

Job Code/Class

Job Status

Employer Contact Person Name

Employer Contact Person Phone Number

Employer Contact Reason

Insured's Contact Person's Name

Insured's Contact Person Phone Number

Insured's Contact Person Reason

Relationship to the Patient Start Date

Relationship to the Patient Stop Date

Insurance Co. Contact Reason

Insurance Co Contact Phone Number

Policy Scope

Policy Source

Patient Member Number

Guarantor's Relationship To Insured

Insured's Phone Number - Home

Insured's Employer Phone Number

Military Handicapped Program

Suspend Flag

Copay Limit Flag

Stoploss Limit Flag

Insured Organization Name and ID

Insured Employer Organization Name and ID

Race

CMS Patient_s Relationship to Insured