| seq | type | opt | description | value |
|---|---|---|---|---|
| 3.1 | O | Guarantor Last Name | ||
| 3.2 | O | Guarantor First Name | ||
| 3.3 | O | Guarantor Middle Initial | ||
| 5.1 | O | Guarantor Address (Line 1) | ||
| 5.2 | O | Guarantor Address (Line 2) | ||
| 5.3 | O | Guarantor City | ||
| 5.4 | O | Guarantor State | ||
| 5.5 | O | Guarantor Zip Code | ||
| 6 | O | Guarantor Phone Number | ||
| 11 | O | Guarantor Relationship to Patient | ’1’ - Self ‘2’ - Spouse ‘3’ - Other |