| seq | type | opt | description | value |
|---|---|---|---|---|
| 2 | R | Elation Patient ID | (Elation Patient ID) | |
| 4 | R | Alternate Patient ID | (Elation Patient ID) | |
| 5.1 | R | Patient Last Name | ||
| 5.2 | R | Patient First Name | ||
| 5.3 | O | Patient Middle Name | ||
| 7 | YYYYMMDD | R | Patient Date of Birth | |
| 8 | R | Patient Gender | ’M’ - Male ‘F’ - Female ‘N’ - Not Indicated | |
| 10 | R | Patient Race | ’1002-5’ - American Indian or Alaska Native ‘2028-9’ - Asian ‘2054-5’ - Black or African American ‘2076-8’ - Native Hawaiian or Other Pacific Islander ‘2106-3’ - White ‘2131-1’ - Other Race ‘0000-0’ - Declined To Specify | |
| 11.1 | O | Patient Address Line 1 | ||
| 11.2 | O | Patient Address Line 2 | ||
| 11.3 | O | Patient City | ||
| 11.4 | O | Patient State | ||
| 11.5 | O | Patient Zip Code | ||
| 13.1 | O | Patient Phone Number | ||
| 13.2 | O | Patient Phone Number Equipment Type | ’CP’ - Cell Phone ‘PH’ - Telephone | |
| 13.4 | O | Patient Email | ||
| 14.1 | O | Alternate Patient Phone Number | ||
| 14.2 | O | Alternate Patient Phone Number Equipment Type | ’CP’ - Cell Phone ‘PH’ - Telephone | |
| 18.1 | O | Secondary Practice Identifier | ||
| 18.4 | O | Bill Type | ’C’ - Client ‘P’ - Patient ‘T’ - Third Party Billing | |
| 22 | O | Patient ethnicity | ’2135-2’ - Hispanic or Latino ‘2186-5’ - Not Hispanic or Latino |
PID|1|1234567891011||1234567891011|LAST^FIRST^MIDDLE||19600120|F|||100 ANY ST^^ANY TOWN^CA^12345|||||||12345678^^^T