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Required Information<br />
FIELD NUMBER NAME AND DESCRIPTION<br />
2 Patient’s Name<br />
Enter the member’s last name and first name exactly as it appears on<br />
the Member Identification card.<br />
3 Date of Birth<br />
Enter the date of birth for the member.<br />
9A Other Insured’s Policy Group Number<br />
Enter the 10 digit Member Identification number exactly as it appears<br />
on the current Member Identification card.<br />
10 Patient’s Condition<br />
Check the appropriate block if applicable.<br />
Cabinet for Health and Family Services<br />
7
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