Patient Secondary 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	Box 9
Birth Date / Sex	Box 9b
Insured ID Number	Box 9a*
Group FECA Number	Box 9a*
Employer	Box 9c
Company Name	Box 9d

* The data for box 9a defaults to using the Group FECA Number.  To change this option, go to the HCFA Settings screen.