Patient Primary Insured

1. Patient Information

2. Primary Insured

3. Secondary Insured

4. Notes/Misc

5. Bill to Information

6. Custom Fields

CMS Form Information	Field
Name/Address/Phone	Box 4, Box 7
Birth Date / Sex	Box 11a
Employer	Box 11b
Insured ID Number	Box 1a
Group FECA Number	Box 11*

For Medicare claims, box 11 will show the word NONE if the Group FECA number is left blank.