LName

Last Name

FName

First Name

MI

Middle Name

PrefName

Preferred Name

Chart

Chart Number

Gender

Sex

Status

Status

FamPos

Family Position

BirthDate

Birthdate

FirstVisit

First Visit Date

WPhone

Work Phone Number

WExt

Work Phone Extension

SS

Social Security Number

Salutation

Custom for Patient

Title

Formal Title (Mr./Mrs.)

OtherID

ID for Medicaid, and so forth

Street

Street Address

Street2

Street Address 2nd line

City

City

State

State

Zip

ZIP Code

HPhone

Home Phone Number

Fax

Fax Number

Pager

Pager Number

OtherNum

Other Number

Email

Email address

DrivLic

Driver’s License Number

Fee_Sched

Fee Schedule Name

HealthHist

Health History

Guar_LName

Guarantor’s Last Name

Guar_FName

Guarantor’s First Name

Aging_0

Balance less than 30 days

Aging_30

Balance over 30 days

Aging_60

Balance over 60 days

Aging_90

Balance over 90 days

Billing_Type

Guarantor’s Billing Type

Balance

Account Balance

LastPayDate

Last Payment Date

LastStmt 

Last Statement Date

PP_Total

F. D. Payment Plan Total

PP_Balance

F. D. Payment Plan Balance

PP_Payment

F. D. Pay Plan Agreed Payment

PP_Payment

F. D. Payment Due Date Date

PMTP_Date

Payment Agreement Date

PMTP_FC

Payment Agreement Finance Charge

PMTP_LC

Payment Agreement Late Charge

PMTP_Interval

Payment Agreement Interval

PMTP_Balance

Payment Agreement Balance

PMTP_PayAmt

Payment Agreement Payment Amt

PMTP_BalRem

Pay Agree Balance Remaining

PMTP_NxtPmt

Payment Agreement Next Payment

PMTP_Amt

Payment Agreement

PstDue 

Amt Past Due

PMTP_RemPmts

Pay Agree Remaining Num Pmts

PMTP_AmtDue

Payment Agreement Amount Due

PMTP_MissPmts

Pay Agree Num of Missed Pmts

Practice_Name

Practice’s Name

Practice_Address

Practice’s Street Address

Practice_Address2 

Practice’s Address2

Practice_Phone

Practice’s Phone

Practice_Phone Ext

Practice’s Phone Ext.

Practice_CitySTZip

Practice’s City, State ZIP

Prov_Name

Primary Provider’s Name

Prov_Title

Primary Provider’s Title

Prov2_Name

Secondary Provider’s Name

Prov2_Title

Secondary Provider's Title

Emp_Name

Employer’s Name

Emp_Add1

Employer’s Street Address

Emp_Street2

Employer’s 2nd Street Line

Emp_Phone

Employer’s Phone Number

PIns_Name

Primary Dental Insurance Name

PIns_Group

Prim Dental Ins Group Name

PIns_RemBenf

Prim Dental Ins Remaining Benefit

PIns_Add1

Prim Dental Ins Street Address

PIns_Add2

Prim Dental Ins Address2

PIns_CitySTZip

Prim Dental Ins City, State, ZIP

PIns_Phone

Prim Dental Ins Phone Number

PIns_Ext

Prim Dental Ins Phone Ext.

PIns_Contact

Prim Dental Insurance Contact

SIns_Name

Sec Dental Insurance Name

SIns_Group

Sec Dental Ins Group Name

SIns_RemBenf

Sec Dental Ins Remaining Benefit

SIns_Add1

Sec Dental Ins Street Address

SIns_Add2

Sec Dental Ins Address2

SIns_CitySTZip

Sec Dental Ins City, State, ZIP

SIns_Phone

Sec Dental Ins Phone Number

SIns_Ext

Sec Dental Ins Phone Ext.

SIns_Contact

Sec Dental Insurance Contact

PMIns_Name

Prim Medical Insurance Name

PMIns_Group

Prim Medical Ins Group Name

PMIns_Add1

Prim Medical Ins Street Address

PMIns_Add2

Prim Medical Ins Street Address2

PMIns_CityST

Prim Medical Ins City, State, Zip

PMIns_Phone

Prim Medical Ins Phone Number

PMIns_Ext

Prim Medical Ins Phone Ext.

PMIns_Contact

Prim Medical Insurance Contact

SMIns_Name

Sec Medical Insurance Name

SMIns_Group

Sec Medical Ins Group Name

SMIns_Add1

Sec Medical Ins Street Address

SMIns_CityST

Sec Medical Ins City, State, Zip

SMIns_Phone

Sec Medical Ins Phone Number

SMIns_Ext

Sec Medical Ins Phone Ext.

SMIns_Contact

Sec Medical Insurance Contact

RefTo_Name

Referred To Last Name/Description

RefTo_Add1

Referred To Street Address

RefTo_Street2

Referred To 2nd Line Street

RefTo_Add2

Referred To City, State, ZIP

RefTo_Phone

Referred To Phone Number

RefTo_Email

Referred To Email Address

RefTo_Date

Date Referral Made

RefTo_FName

Referred To First Name

RefTo_MI

Referred To Middle Initial

RefTo_

Custom for Referral Salutation

RefBy_Name

Referred By Name

RefBy_Add1

Referred By Street Address

RefBy_Street2

Referred By 2nd Street Line

RefBy_Add2

Referred By City, State, ZIP

RefBy_Phone

Referred By Phone Number

RefBy_Email 

Referred By Email Address

RefBy_FName

Referred By First Name

RefBy_MI

Referred By Middle Initial

RefBy_

Custom for Referral Salutation

LastVisit

Patient’s Last Visit Date

LastRef

Last Referral Date

LastMissed

Last Missed Appointment Date

RefTo_Title

Referred To Title

RefBy_Title

Referred By Title

Appt_Date

Next Appointment Date

Appt_Time

Next Appointment Time

Appt_Reason

Next Appointment Reason

Appt_Name

New Patient Appointment Name

Appt_Provider

Next Appointment Provider

Appt_Phone

New Patient Appt Phone Number

Appt_Add1

New Patient Appt Street Address

Appt_Street2

New Patient Appt 2nd Street Line

Appt_Add2

New Patient Appt State, ZIP

CC_DueDate

Continuing Care Due Date

CC_TypeName

Continuing Care Type Name

CC_TypeDesc

Continuing Care Description

CC_Note

Continuing Care Note

CC_PriorWork

Continuing Care Date Prior Treatment Date

CC_StatusType

Continuing Care Status Type

CC_StatusDesc

Continuing Care Status Description

CC_ApptDate

Continuing Care Appointment Date

CC_ApptTime

Continuing Care Appointment Time

CC_ApptReason

Continuing Care Appointment Reason

CC_ApptProv

Continuing Care Appointment