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The active session is the most recently modified `~/.claude/projects//.jsonl`; this skill POSTs that file to the InstaShare API in one shell call and prints the returned URL. Use when the user asks to \\\"share this chat\\\", \\\"make a link to this conversation\\\", \\\"InstaShare this\\\", \\\"publish this session\\\", or similar.\\n- clean-feature-docs: Remove Internal Implementation Details from Feature Docs\\n- reorganize-feature-categories: Reorganize Feature Doc Categories\\n- rewrite-feature: Rewrite Instafill.ai Feature Description\\n- deep-research: Deep research harness — fan-out web searches, fetch sources, adversarially verify claims, synthesize a cited report. - When the user wants a deep, multi-source, fact-checked research report on any topic. BEFORE invoking, check if the question is specific enough to research directly — if underspecified (e.g., \\\"what car to buy\\\" without budget/use-case/region), ask 2-3 clarifying questions to narrow scope. 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For simple settings like theme/model, suggest the /config command.\\n- keybindings-help: Use when the user wants to customize keyboard shortcuts, rebind keys, add chord bindings, or modify ~/.claude/keybindings.json. Examples: \\\"rebind ctrl+s\\\", \\\"add a chord shortcut\\\", \\\"change the submit key\\\", \\\"customize keybindings\\\".\\n- verify: Verify that a code change actually does what it's supposed to by running the app and observing behavior. Use when asked to verify a PR, confirm a fix works, test a change manually, check that a feature works, or validate local changes before pushing.\\n- code-review: Review the current diff for correctness bugs and reuse/simplification/efficiency cleanups at the given effort level (low/medium: fewer, high-confidence findings; high→max: broader coverage, may include uncertain findings; ultra: deep multi-agent review in the cloud). Pass --comment to post findings as inline PR comments, or --fix to apply the findings to the working tree after the review.\\n- simplify: Review the changed code for reuse, simplification, efficiency, and altitude cleanups, then apply the fixes. Quality only — it does not hunt for bugs; use /code-review for that.\\n- fewer-permission-prompts: Scan your transcripts for common read-only Bash and MCP tool calls, then add a prioritized allowlist to project .claude/settings.json to reduce permission prompts.\\n- loop: Run a prompt or slash command on a recurring interval (e.g. /loop 5m /foo). Omit the interval to let the model self-pace. - When the user wants to set up a recurring task, poll for status, or run something repeatedly on an interval (e.g. \\\"check the deploy every 5 minutes\\\", \\\"keep running /babysit-prs\\\"). Do NOT invoke for one-off tasks.\\n- schedule: Create, update, list, or run scheduled cloud agents (routines) that execute on a cron schedule. - When the user wants to schedule a recurring cloud agent, set up automated tasks, create a cron job for Claude Code, or manage their scheduled agents/routines. Also use when the user wants a one-time scheduled run (\\\"run this once at 3pm\\\", \\\"remind me to check X tomorrow\\\").\\n- claude-api: Reference for the Claude API / Anthropic SDK — model ids, pricing, params, streaming, tool use, MCP, agents, caching, token counting, model migration.\\nTRIGGER — read BEFORE opening the target file; don't skip because it \\\"looks like a one-liner\\\" — whenever: the prompt names Claude/Anthropic in any form (Claude, Anthropic, Fable, Opus, Sonnet, Haiku, `anthropic`, `@anthropic-ai`, `claude-*`, `us.anthropic.*`, `[1m]`); the user asks about an LLM (pricing/model choice/limits/caching) — never answer from memory; OR the task is LLM-shaped with provider unstated (agent/MCP/tool-definition/multi-agent/RAG/LLM-judge/computer-use; generate/summarize/extract/classify/rewrite/converse over NL; debugging refusals/cutoffs/streaming/tool-calls/tokens).\\nSKIP only when another provider is being worked on (overrides all triggers): OpenAI/GPT/Gemini/Llama/Mistral/Cohere/Ollama named in the query; OR `grep -rE 'openai|langchain_openai|google.generativeai|genai|mistralai|cohere|ollama'` over the project hits (run this grep FIRST if no provider named — don't Read the file).\\n- run: Launch and drive this project's app to see a change working. 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Listed newest first:\\n\\n| # | Form | Pages | Created |\\n|---|------|-------|---------|\\n| 1 | cms-1500-02-12-health-insurance-claim-form.pdf | 2 | 2026-06-16 |\\n| 2 | 1199seiu-benefit-funds-aba-prior-authorization-form.pdf | 3 | 2026-06-02 |\\n| 3 | uniform-residential-loan-application-freddie-mac-f.pdf | 9 | 2026-04-29 |\\n| 4 | aba-authorization-request-medi-cal-initial-and-concurrent-requests.pdf | 2 | 2026-04-29 |\\n| 5 | aba-authorization-request-medi-cal-initial-and-concurrent-requests.pdf | 2 | 2026-04-29 |\\n| 6 | w-9.pdf | 6 | 2026-04-29 |\\n| 7 | w-9.pdf | 6 | 2026-04-29 |\\n| 8 | URLA-2019-Borrower-v28.pdf | 9 | 2026-04-17 |\\n| 9 | Formular_für_Betonabbruch.php.pdf | 1 | 2026-04-10 |\\n| 10 | ABA_referral_form.pdf | 2 | 2026-04-08 |\\n| 11 | g-28.pdf | 4 | 2026-04-07 |\\n| 12 | f4562.pdf | 3 | 2026-04-06 |\\n| 13 | ABA-Referral-Form.pdf | 2 | 2026-04-03 |\\n| 14 | Clinical-Review-for-ASD-and-ABA.pdf | 1 | 2026-03-30 |\\n| 15 | cm010.pdf | 3 | 2026-03-23 |\\n| 16 | cuaderno_de_campo_editable.pdf | 43 | 2026-03-20 |\\n| 17 | CFS_602.pdf | 2 | 2026-03-20 |\\n| 18 | Form-16.pdf | 4 | 2026-03-20 |\\n| 19 | IMMOVABEL-FORM-18-2-I-...pdf | 3 | 2026-03-19 |\\n| 20 | FORM-NO-15G.pdf | 3 | 2026-03-19 |\\n| 21 | cm010.pdf | 3 | 2026-03-16 |\\n| 22 | test.pdf | 1 | 2026-02-10 |\\n| 23 | 02-10-2026_Mariana_extra_page_rotation0.pdf | 1 | 2026-02-10 |\\n| 24 | 02-10-2026_Mariana_extra_page.pdf | 1 | 2026-02-10 |\\n| 25 | Ausschreibung-Test1.pdf | 18 | 2026-02-10 |\\n| 26 | cm010.pdf | 3 | 2026-02-06 |\\n| 27 | Ausschreibung-Test1.pdf | 18 | 2026-02-06 |\\n| 28 | complaint_for_employment_discrimination.pdf | 6 | 2026-02-05 |\\n| 29 | complaint_for_employment_discrimination_watermark.pdf | 6 | 2026-02-05 |\\n| 30 | RM26-Accessibility_Form.pdf | 3 | 2026-02-05 |\\n| 31 | f4562.pdf | 3 | 2026-02-03 |\\n| 32 | SoCP Application Form (v1.00 06/2014) | — | 2026-02-03 |\\n| 33 | cm010.pdf | 3 | 2026-02-03 |\\n| 34 | document.pdf | 16 | 2026-02-03 |\\n| 35 | SC-104 | — | 2026-02-03 |\\n| 36 | Application for Lease 4301 | — | 2026-02-02 |\\n| 37 | CFS_602_Medical_Rpt...(Fillable).pdf | — | 2026-02-02 |\\n| 38 | CFS_602_Medical_Rpt...(Fillable).pdf | — | 2026-02-02 |\\n| 39 | EEOC_Form_5.pdf | 3 | 2026-01-26 |\\n| 40 | EEOC_Form_5.pdf | 3 | 2026-01-26 |\\n| 41 | EEOC_Form_5.pdf | 3 | 2026-01-26 |\\n| 42 | EEOC Form 5.pdf | 3 | 2026-01-26 |\\n| 43 | SHA_DBQ_Part_A_Self-Assessment.pdf | 16 | 2026-01-23 |\\n| 44 | lhl234.pdf | 20 | 2026-01-14 |\\n| 45 | f1040--dft.pdf | 2 | 2026-01-09 |\\n| 46 | f1040--dft.pdf | 2 | 2026-01-08 |\\n| 47 | REG-156-R11-2024-ASB-WWW.pdf | 2 | 2026-01-07 |\\n| 48 | f1040--dft.pdf | 2 | 2026-01-07 |\\n| 49 | f1040--dft.pdf | 2 | 2026-01-07 |\\n| 50 | i-9.pdf | 4 | 2026-01-06 |\\n| 51 | Application for Employment, Form AO-78 | 5 | 2026-01-06 |\\n| 52 | REG-156 | 2 | 2026-01-06 |\\n| 53 | Employment Eligibility Verification, Form I-9 | 4 | 2026-01-06 |\\n\\nWant me to filter/search these (e.g. only ABA, tax, or loan forms), pull field details for a specific one, or start a fill?\"}],\"stop_reason\":\"end_turn\",\"stop_sequence\":null,\"stop_details\":null,\"usage\":{\"input_tokens\":2,\"cache_creation_input_tokens\":5095,\"cache_read_input_tokens\":30330,\"output_tokens\":1973,\"server_tool_use\":{\"web_search_requests\":0,\"web_fetch_requests\":0},\"service_tier\":\"standard\",\"cache_creation\":{\"ephemeral_1h_input_tokens\":5095,\"ephemeral_5m_input_tokens\":0},\"inference_geo\":\"not_available\",\"iterations\":[{\"input_tokens\":2,\"output_tokens\":1973,\"cache_read_input_tokens\":30330,\"cache_creation_input_tokens\":5095,\"cache_creation\":{\"ephemeral_5m_input_tokens\":0,\"ephemeral_1h_input_tokens\":5095},\"type\":\"message\"}],\"speed\":\"standard\"},\"diagnostics\":null},\"requestId\":\"req_011Cc7PbBtqLKs1VGz3KZU8t\",\"attributionMcpServer\":\"claude.ai Instafill\",\"attributionMcpTool\":\"list_forms\",\"type\":\"assistant\",\"uuid\":\"a7676bde-2436-47b3-b1c3-e6b0f86439b2\",\"timestamp\":\"2026-06-16T18:12:08.859Z\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"c:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"type\":\"queue-operation\",\"operation\":\"enqueue\",\"timestamp\":\"2026-06-16T18:13:29.177Z\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\"}\n{\"type\":\"queue-operation\",\"operation\":\"dequeue\",\"timestamp\":\"2026-06-16T18:13:29.177Z\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\"}\n{\"parentUuid\":\"a7676bde-2436-47b3-b1c3-e6b0f86439b2\",\"isSidechain\":false,\"promptId\":\"b60343ba-e2ea-4c45-a941-ef9f191863f3\",\"type\":\"user\",\"message\":{\"role\":\"user\",\"content\":[{\"type\":\"text\",\"text\":\"fill out cms 1500 using this data:\\n\\n1. 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Diagnosis Code, [blank]\\n22. Resubmission Code, [blank]\\n22. Original Ref. No., [blank]\\n23. Prior Authorization Number, [blank]\\n\\n24. Line 1 - A. Date(s) of Service From, 06 09 2026\\n24. Line 1 - A. Date(s) of Service To, 06 09 2026\\n24. Line 1 - B. Place of Service, 11\\n24. Line 1 - C. EMG, [blank]\\n24. Line 1 - D. CPT/HCPCS, 99213\\n24. Line 1 - D. Modifier, 25\\n24. Line 1 - E. Diagnosis Pointer, A\\n24. Line 1 - F. $ Charges, 145.00\\n24. Line 1 - G. Days or Units, 1\\n24. Line 1 - H. EPSDT/Family Plan, [blank]\\n24. Line 1 - I. ID Qual., [blank]\\n24. Line 1 - J. Rendering Provider ID #, 1295087643\\n\\n24. Line 2 - A. Date(s) of Service From, 06 09 2026\\n24. Line 2 - A. Date(s) of Service To, 06 09 2026\\n24. Line 2 - B. Place of Service, 11\\n24. Line 2 - C. EMG, [blank]\\n24. Line 2 - D. CPT/HCPCS, 72100\\n24. Line 2 - D. Modifier, [blank]\\n24. Line 2 - E. Diagnosis Pointer, A B\\n24. Line 2 - F. $ Charges, 210.00\\n24. Line 2 - G. Days or Units, 1\\n24. 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find the field by inspecting the form's fields, then update its control type. Let me load those tools.\"}],\"stop_reason\":\"tool_use\",\"stop_sequence\":null,\"stop_details\":null,\"usage\":{\"input_tokens\":2,\"cache_creation_input_tokens\":349,\"cache_read_input_tokens\":43910,\"output_tokens\":254,\"server_tool_use\":{\"web_search_requests\":0,\"web_fetch_requests\":0},\"service_tier\":\"standard\",\"cache_creation\":{\"ephemeral_1h_input_tokens\":349,\"ephemeral_5m_input_tokens\":0},\"inference_geo\":\"not_available\",\"iterations\":[{\"input_tokens\":2,\"output_tokens\":254,\"cache_read_input_tokens\":43910,\"cache_creation_input_tokens\":349,\"cache_creation\":{\"ephemeral_5m_input_tokens\":0,\"ephemeral_1h_input_tokens\":349},\"type\":\"message\"}],\"speed\":\"standard\"},\"diagnostics\":null},\"requestId\":\"req_011Cc7PtwWePZBKYU8bsY5aY\",\"type\":\"assistant\",\"uuid\":\"ea424295-b9bc-46d7-a425-44345f963823\",\"timestamp\":\"2026-06-16T18:15:55.630Z\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"c:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"parentUuid\":\"ea424295-b9bc-46d7-a425-44345f963823\",\"isSidechain\":false,\"message\":{\"model\":\"claude-opus-4-8\",\"id\":\"msg_016kY3RvJEfg8vzSTk5Pnv9b\",\"type\":\"message\",\"role\":\"assistant\",\"content\":[{\"type\":\"tool_use\",\"id\":\"toolu_01B4tHnehqVpY35q3hWSU1rs\",\"name\":\"ToolSearch\",\"input\":{\"query\":\"select:mcp__claude_ai_Instafill__get_form_fields,mcp__claude_ai_Instafill__update_form_fields\",\"max_results\":2},\"caller\":{\"type\":\"direct\"}}],\"stop_reason\":\"tool_use\",\"stop_sequence\":null,\"stop_details\":null,\"usage\":{\"input_tokens\":2,\"cache_creation_input_tokens\":349,\"cache_read_input_tokens\":43910,\"output_tokens\":254,\"server_tool_use\":{\"web_search_requests\":0,\"web_fetch_requests\":0},\"service_tier\":\"standard\",\"cache_creation\":{\"ephemeral_1h_input_tokens\":349,\"ephemeral_5m_input_tokens\":0},\"inference_geo\":\"not_available\",\"iterations\":[{\"input_tokens\":2,\"output_tokens\":254,\"cache_read_input_tokens\":43910,\"cache_creation_input_tokens\":349,\"cache_creation\":{\"ephemeral_5m_input_tokens\":0,\"ephemeral_1h_input_tokens\":349},\"type\":\"message\"}],\"speed\":\"standard\"},\"diagnostics\":null},\"requestId\":\"req_011Cc7PtwWePZBKYU8bsY5aY\",\"type\":\"assistant\",\"uuid\":\"2f720bbc-b0f8-47ba-9b3e-6bc1d7be78aa\",\"timestamp\":\"2026-06-16T18:15:55.951Z\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"c:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"parentUuid\":\"2f720bbc-b0f8-47ba-9b3e-6bc1d7be78aa\",\"isSidechain\":false,\"promptId\":\"6301aad3-e064-44e4-8397-fa03af66d65d\",\"type\":\"user\",\"message\":{\"role\":\"user\",\"content\":[{\"type\":\"tool_result\",\"tool_use_id\":\"toolu_01B4tHnehqVpY35q3hWSU1rs\",\"content\":[{\"type\":\"tool_reference\",\"tool_name\":\"mcp__claude_ai_Instafill__get_form_fields\"},{\"type\":\"tool_reference\",\"tool_name\":\"mcp__claude_ai_Instafill__update_form_fields\"}]}]},\"uuid\":\"3a07b4a1-2408-49a5-9925-8922a7ddd36f\",\"timestamp\":\"2026-06-16T18:15:55.959Z\",\"toolUseResult\":{\"matches\":[\"mcp__claude_ai_Instafill__get_form_fields\",\"mcp__claude_ai_Instafill__update_form_fields\"],\"query\":\"select:mcp__claude_ai_Instafill__get_form_fields,mcp__claude_ai_Instafill__update_form_fields\",\"total_deferred_tools\":80},\"sourceToolAssistantUUID\":\"2f720bbc-b0f8-47ba-9b3e-6bc1d7be78aa\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"c:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"parentUuid\":\"3a07b4a1-2408-49a5-9925-8922a7ddd36f\",\"isSidechain\":false,\"message\":{\"model\":\"claude-opus-4-8\",\"id\":\"msg_01XTFz9EoricGg7yaGM6Df7t\",\"type\":\"message\",\"role\":\"assistant\",\"content\":[{\"type\":\"tool_use\",\"id\":\"toolu_01LoymQnDLMzJLowfZsar4ZE\",\"name\":\"mcp__claude_ai_Instafill__get_form_fields\",\"input\":{\"formId\":\"6a3185a67577317a2d1300ae\"},\"caller\":{\"type\":\"direct\"}}],\"stop_reason\":\"tool_use\",\"stop_sequence\":null,\"stop_details\":null,\"usage\":{\"input_tokens\":2,\"cache_creation_input_tokens\":1446,\"cache_read_input_tokens\":44259,\"output_tokens\":80,\"server_tool_use\":{\"web_search_requests\":0,\"web_fetch_requests\":0},\"service_tier\":\"standard\",\"cache_creation\":{\"ephemeral_1h_input_tokens\":1446,\"ephemeral_5m_input_tokens\":0},\"inference_geo\":\"not_available\",\"iterations\":[{\"input_tokens\":2,\"output_tokens\":80,\"cache_read_input_tokens\":44259,\"cache_creation_input_tokens\":1446,\"cache_creation\":{\"ephemeral_5m_input_tokens\":0,\"ephemeral_1h_input_tokens\":1446},\"type\":\"message\"}],\"speed\":\"standard\"},\"diagnostics\":null},\"requestId\":\"req_011Cc7PuLm8aVst4BC1fkbNV\",\"type\":\"assistant\",\"uuid\":\"ac80c794-43f0-4772-9c27-aa1d5b08e0d9\",\"timestamp\":\"2026-06-16T18:15:58.659Z\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"c:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"parentUuid\":\"ac80c794-43f0-4772-9c27-aa1d5b08e0d9\",\"isSidechain\":false,\"promptId\":\"6301aad3-e064-44e4-8397-fa03af66d65d\",\"type\":\"user\",\"message\":{\"role\":\"user\",\"content\":[{\"tool_use_id\":\"toolu_01LoymQnDLMzJLowfZsar4ZE\",\"type\":\"tool_result\",\"content\":\"Error: result (64,859 characters) exceeds maximum allowed tokens. Output has been saved to C:\\\\Users\\\\smirn\\\\.claude\\\\projects\\\\c--Users-smirn-OneDrive-Documents-GitHub-botmakers-projects-copilot-us-instafill-ai\\\\986638d6-b238-4e02-83a0-449ec3df5830\\\\tool-results\\\\mcp-claude_ai_Instafill-get_form_fields-1781633763810.txt.\\nFormat: JSON with schema: {form_id: string, groups: [{...}]}\\n- For targeted queries (find a value, filter by field): use jq on the file directly.\\n- For analysis or summarization that requires reading the full content: first probe the structure (e.g., jq 'type, length, keys?' C:\\\\Users\\\\smirn\\\\.claude\\\\projects\\\\c--Users-smirn-OneDrive-Documents-GitHub-botmakers-projects-copilot-us-instafill-ai\\\\986638d6-b238-4e02-83a0-449ec3df5830\\\\tool-results\\\\mcp-claude_ai_Instafill-get_form_fields-1781633763810.txt), then extract slices with jq or python — Read's line-based offset/limit will not chunk this file.\\n- If the Agent tool is available, do this inside a subagent so the full output stays out of your main context. Give it the instruction above verbatim, and be explicit about what it must return — e.g. \\\"C:\\\\Users\\\\smirn\\\\.claude\\\\projects\\\\c--Users-smirn-OneDrive-Documents-GitHub-botmakers-projects-copilot-us-instafill-ai\\\\986638d6-b238-4e02-83a0-449ec3df5830\\\\tool-results\\\\mcp-claude_ai_Instafill-get_form_fields-1781633763810.txt is JSON with schema: {form_id: string, groups: [{...}]}; probe the structure with jq (type/length/keys), then extract and read the content in full with jq or python, then summarize and quote any key findings verbatim.\\\" A vague \\\"summarize this\\\" may lose detail.\\n\"}]},\"uuid\":\"c44a7285-bb96-4c15-96f4-d9f1ef74dfec\",\"timestamp\":\"2026-06-16T18:16:03.838Z\",\"toolUseResult\":\"Error: result (64,859 characters) exceeds maximum allowed tokens. Output has been saved to C:\\\\Users\\\\smirn\\\\.claude\\\\projects\\\\c--Users-smirn-OneDrive-Documents-GitHub-botmakers-projects-copilot-us-instafill-ai\\\\986638d6-b238-4e02-83a0-449ec3df5830\\\\tool-results\\\\mcp-claude_ai_Instafill-get_form_fields-1781633763810.txt.\\nFormat: JSON with schema: {form_id: string, groups: [{...}]}\\n- For targeted queries (find a value, filter by field): use jq on the file directly.\\n- For analysis or summarization that requires reading the full content: first probe the structure (e.g., jq 'type, length, keys?' C:\\\\Users\\\\smirn\\\\.claude\\\\projects\\\\c--Users-smirn-OneDrive-Documents-GitHub-botmakers-projects-copilot-us-instafill-ai\\\\986638d6-b238-4e02-83a0-449ec3df5830\\\\tool-results\\\\mcp-claude_ai_Instafill-get_form_fields-1781633763810.txt), then extract slices with jq or python — Read's line-based offset/limit will not chunk this file.\\n- If the Agent tool is available, do this inside a subagent so the full output stays out of your main context. Give it the instruction above verbatim, and be explicit about what it must return — e.g. \\\"C:\\\\Users\\\\smirn\\\\.claude\\\\projects\\\\c--Users-smirn-OneDrive-Documents-GitHub-botmakers-projects-copilot-us-instafill-ai\\\\986638d6-b238-4e02-83a0-449ec3df5830\\\\tool-results\\\\mcp-claude_ai_Instafill-get_form_fields-1781633763810.txt is JSON with schema: {form_id: string, groups: [{...}]}; probe the structure with jq (type/length/keys), then extract and read the content in full with jq or python, then summarize and quote any key findings verbatim.\\\" A vague \\\"summarize this\\\" may lose detail.\\n\",\"mcpMeta\":{\"structuredContent\":{\"form_id\":\"6a3185a67577317a2d1300ae\",\"groups\":[{\"group\":\"Payer/Carrier Codes (PICA)\",\"fields\":[{\"id\":\"c989\",\"name\":\"PICA Code (Left)\",\"description\":\"Enter the Payer/Carrier Code (PICA) shown on your insurance card or provided by your plan for this claim.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"form_max_length\":3,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"2b19\",\"name\":\"PICA Code (Right)\",\"description\":\"Enter the Payer/Carrier Code (PICA) for the carrier receiving this claim, if a separate PICA code is required.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"form_max_length\":3,\"page_num\":0,\"section\":\"Page 1\"}]},{\"fields\":[{\"id\":\"0b89\",\"name\":\"PICA1 (top left)\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"d80d\",\"name\":\"PICA2 (top left)\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"05e2\",\"name\":\"PICA3 (top left)\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"6ccf\",\"name\":\"PICA1 (top right)\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"f67e\",\"name\":\"PICA2 (top right)\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"4332\",\"name\":\"PICA3 (top right)\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Insurance Program Selection\",\"fields\":[{\"id\":\"f943\",\"name\":\"Medicare\",\"description\":\"Check this box if the patient’s coverage for this claim is through Medicare.\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"0760\",\"name\":\"Medicaid\",\"description\":\"Check this box if the patient’s coverage for this claim is through Medicaid.\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"5c95\",\"name\":\"TRICARE\",\"description\":\"Check this box if the patient’s coverage for this claim is through TRICARE.\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"1ec2\",\"name\":\"CHAMPVA\",\"description\":\"Check this box if the patient’s coverage for this claim is through CHAMPVA.\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"c790\",\"name\":\"Group Health Plan\",\"description\":\"Check this box if the patient’s coverage for this claim is through a Group Health Plan.\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"3191\",\"name\":\"FECA / Black Lung\",\"description\":\"Check this box if the claim is covered under FECA or the Black Lung program.\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"680e\",\"name\":\"Other\",\"description\":\"Check this box if the patient’s coverage for this claim is through another program not listed and enter the program ID number.\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Patient & Insured Basic Info\",\"fields\":[{\"id\":\"fec6\",\"name\":\"Insured ID Number\",\"description\":\"Enter the insured person’s identification number exactly as shown on the insurance card. Fill only if 'Medicare', 'Medicaid', 'TRICARE', 'CHAMPVA', 'Group Health Plan', 'FECA / Black Lung', 'Other' is 'Yes' (any).\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\",\"depends_on\":[\"f943\",\"0760\",\"5c95\",\"1ec2\",\"c790\",\"3191\",\"680e\"]},{\"id\":\"83f4\",\"name\":\"Patient Name\",\"description\":\"Enter the patient’s full name (last name, first name, and middle initial).\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"f8\",\"name\":\"Patient Birth Month\",\"description\":\"Enter the month of the patient’s date of birth.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"72\",\"name\":\"Patient Birth Day\",\"description\":\"Enter the day of the month of the patient’s date of birth.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"a3\",\"name\":\"Patient Birth Year\",\"description\":\"Enter the year of the patient’s date of birth.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"6e4b\",\"name\":\"Sex: Male\",\"description\":\"Check this box if the patient is male.\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"8f5a\",\"name\":\"Sex: Female\",\"description\":\"Check this box if the patient is female.\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"8150\",\"name\":\"Insured Name\",\"description\":\"Enter the insured person’s full name (last name, first name, and middle initial).\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Patient Address & Phone\",\"fields\":[{\"id\":\"ae3b\",\"name\":\"Patient Street Address\",\"description\":\"Enter the patient's street address (house/building number and street name).\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"1b45\",\"name\":\"Patient City\",\"description\":\"Enter the city where the patient lives.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"7c90\",\"name\":\"Patient State\",\"description\":\"Enter the state where the patient lives.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"f0b6\",\"name\":\"Patient ZIP Code\",\"description\":\"Enter the patient's ZIP or postal code.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"8942\",\"name\":\"Patient Telephone (Area Code)\",\"description\":\"Enter the area code for the patient's telephone number.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"00c3\",\"name\":\"Patient Telephone Number\",\"description\":\"Enter the patient's telephone number.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Patient Relationship to Insured\",\"fields\":[{\"id\":\"dfee\",\"name\":\"Self\",\"description\":\"Check this box if the patient is the insured person (the policyholder).\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"d5ee\",\"name\":\"Spouse\",\"description\":\"Check this box if the patient is the insured person’s spouse.\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"1f71\",\"name\":\"Child\",\"description\":\"Check this box if the patient is the insured person’s child (dependent).\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"9e9b\",\"name\":\"Other\",\"description\":\"Check this box if the patient’s relationship to the insured is not self, spouse, or child.\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Insured Address & Phone\",\"fields\":[{\"id\":\"ae1c\",\"name\":\"Insured Street Address\",\"description\":\"Enter the insured’s street address (number and street name).\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"8013\",\"name\":\"Insured City\",\"description\":\"Enter the city for the insured’s mailing address.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"7f05\",\"name\":\"Insured State\",\"description\":\"Enter the state for the insured’s mailing address.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"d72b\",\"name\":\"Insured ZIP Code\",\"description\":\"Enter the ZIP code for the insured’s mailing address.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"d7f2\",\"name\":\"Insured Phone Area Code\",\"description\":\"Enter the area code for the insured’s telephone number.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"f653\",\"name\":\"Insured Phone Number\",\"description\":\"Enter the insured’s telephone number excluding the area code.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Reserved for NUCC Use (Item 8)\",\"fields\":[{\"id\":\"f96d\",\"name\":\"NUCC Use (Item 8)\",\"description\":\"Enter any code or information provided by NUCC for Item 8, if applicable; otherwise leave blank.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Other Insured Information\",\"fields\":[{\"id\":\"8e7b\",\"name\":\"Other Insured Name\",\"description\":\"Enter the other insured person’s full name (last name, first name, middle initial) as it appears on their insurance card. Fill only if 'Yes' is 'Yes'.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\",\"depends_on\":[\"0a95\"]},{\"id\":\"e047\",\"name\":\"Other Insured Policy/Group Number\",\"description\":\"Enter the policy number or group number for the other insured person’s health plan. Fill only if 'Yes' is 'Yes'.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\",\"depends_on\":[\"0a95\"]},{\"id\":\"8519\",\"name\":\"Reserved for NUCC Use (9b)\",\"description\":\"Enter the value requested for this reserved NUCC field, if instructed to do so by the payer. Fill only if 'Yes' is 'Yes'.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\",\"depends_on\":[\"0a95\"]},{\"id\":\"f3d3\",\"name\":\"Reserved for NUCC Use (9c)\",\"description\":\"Enter the value requested for this reserved NUCC field, if instructed to do so by the payer. Fill only if 'Yes' is 'Yes'.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\",\"depends_on\":[\"0a95\"]},{\"id\":\"29cf\",\"name\":\"Other Insurance Plan/Program Name\",\"description\":\"Enter the name of the other insured person’s insurance plan or program. Fill only if 'Yes' is 'Yes'.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\",\"depends_on\":[\"0a95\"]}]},{\"group\":\"Patient Condition Related To (Employment/Accidents)\",\"fields\":[{\"id\":\"c11a\",\"name\":\"Employment? (Current or Previous) — Yes\",\"description\":\"Check this box if the patient’s condition is related to current or previous employment.\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"5f7a\",\"name\":\"Employment? (Current or Previous) — No\",\"description\":\"Check this box if the patient’s condition is not related to current or previous employment.\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"856a\",\"name\":\"Auto Accident? — Yes\",\"description\":\"Check this box if the patient’s condition is related to an automobile accident.\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"66a9\",\"name\":\"Auto Accident? — No\",\"description\":\"Check this box if the patient’s condition is not related to an automobile accident.\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"97\",\"name\":\"Auto Accident Location (State)\",\"description\":\"Enter the U.S. state where the auto accident occurred, if the patient’s condition is related to an auto accident. Fill only if 'Auto Accident? — Yes' is 'Yes'.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\",\"depends_on\":[\"856a\"]},{\"id\":\"0304\",\"name\":\"Other Accident? — Yes\",\"description\":\"Check this box if the patient’s condition is related to an accident other than an auto accident.\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"8498\",\"name\":\"Other Accident? — No\",\"description\":\"Check this box if the patient’s condition is not related to any accident other than an auto accident.\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Claim Codes (10d)\",\"fields\":[{\"id\":\"5fb8\",\"name\":\"Claim Codes (10d)\",\"description\":\"Enter any applicable claim codes for this claim as designated by the NUCC.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Insured Policy & Demographics\",\"fields\":[{\"id\":\"99ec\",\"name\":\"Insured Policy Group or FECA Number\",\"description\":\"Enter the insured person’s policy group number or FECA number as shown on the insurance information.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"b6\",\"name\":\"Insured Date of Birth (Month)\",\"description\":\"Enter the month of the insured person’s date of birth.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"c2\",\"name\":\"Insured Date of Birth (Day)\",\"description\":\"Enter the day of the month of the insured person’s date of birth.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"7a\",\"name\":\"Insured Date of Birth (Year)\",\"description\":\"Enter the year of the insured person’s date of birth.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"b8b4\",\"name\":\"Sex - Male (M)\",\"description\":\"Check this box if the insured person is male.\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"7eba\",\"name\":\"Sex - Female (F)\",\"description\":\"Check this box if the insured person is female.\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Other Claim ID & Plan Name\",\"fields\":[{\"id\":\"f73d\",\"name\":\"Other Claim ID Qualifier\",\"description\":\"Enter the qualifier code that identifies the type/source of the other claim ID.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"6f67\",\"name\":\"Other Claim ID\",\"description\":\"Enter the other claim identification number associated with the patient’s coverage.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"a80e\",\"name\":\"Other Insurance Plan Name\",\"description\":\"Enter the name of the other insurance plan or program related to the other claim.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Another Health Benefit Plan (11d)\",\"fields\":[{\"id\":\"0a95\",\"name\":\"Yes\",\"description\":\"Check this box if the patient is covered by another health benefit plan in addition to the plan listed on this claim.\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"2176\",\"name\":\"No\",\"description\":\"Check this box if the patient is not covered by any other health benefit plan besides the plan listed on this claim.\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Patient/Insured Signatures & Dates\",\"fields\":[{\"id\":\"26e3\",\"name\":\"Patient/Authorized Person Signature\",\"description\":\"Enter the signature of the patient or the authorized person who is signing to authorize release of information and payment of benefits.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"b072\",\"name\":\"Signature Date (Patient/Authorized Person)\",\"description\":\"Enter the date the patient or authorized person signed the form.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"5f65\",\"name\":\"Insured/Authorized Person Signature\",\"description\":\"Enter the signature of the insured or authorized person authorizing payment of medical benefits to the provider or supplier.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Illness/Injury/Other Dates (Items 14-15)\",\"fields\":[{\"id\":\"ae\",\"name\":\"Current Illness/Injury Date - Month\",\"description\":\"Enter the month of the date of current illness, injury, or pregnancy (LMP).\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"47\",\"name\":\"Current Illness/Injury Date - Day\",\"description\":\"Enter the day of the date of current illness, injury, or pregnancy (LMP).\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"4e\",\"name\":\"Current Illness/Injury Date - Year\",\"description\":\"Enter the year of the date of current illness, injury, or pregnancy (LMP).\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"9de9\",\"name\":\"Current Illness/Injury Date Qualifier\",\"description\":\"Enter the qualifier code that indicates what the date of current illness, injury, or pregnancy represents.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"6c28\",\"name\":\"Other Date Qualifier\",\"description\":\"Enter the qualifier code that indicates what the other date represents.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"02\",\"name\":\"Other Date - Month\",\"description\":\"Enter the month for the other date indicated by the qualifier.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"bd\",\"name\":\"Other Date - Day\",\"description\":\"Enter the day for the other date indicated by the qualifier.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"f7\",\"name\":\"Other Date - Year\",\"description\":\"Enter the year for the other date indicated by the qualifier.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Unable to Work Dates (Item 16)\",\"fields\":[{\"id\":\"ef\",\"name\":\"Unable to Work From (Month)\",\"description\":\"Enter the month when the patient first became unable to work in their current occupation.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"1d\",\"name\":\"Unable to Work From (Day)\",\"description\":\"Enter the day of the month when the patient first became unable to work in their current occupation.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"9c\",\"name\":\"Unable to Work From (Year)\",\"description\":\"Enter the year when the patient first became unable to work in their current occupation.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"bf\",\"name\":\"Unable to Work To (Month)\",\"description\":\"Enter the month when the patient returned to work (or the end month of the period they were unable to work).\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"b8\",\"name\":\"Unable to Work To (Day)\",\"description\":\"Enter the day of the month when the patient returned to work (or the end day of the period they were unable to work).\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"a4\",\"name\":\"Unable to Work To (Year)\",\"description\":\"Enter the year when the patient returned to work (or the end year of the period they were unable to work).\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Referring Provider Information (Item 17)\",\"fields\":[{\"id\":\"a14e\",\"name\":\"Referring provider last name\",\"description\":\"Enter the referring provider’s last name.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"c3d3\",\"name\":\"Referring provider first name\",\"description\":\"Enter the referring provider’s first name (and middle initial if applicable).\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"2bbb\",\"name\":\"Referring provider ID qualifier (17a)\",\"description\":\"Enter the qualifier that identifies the type of non-NPI referring provider ID reported in Item 17a.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"8d84\",\"name\":\"Referring provider ID number (17a)\",\"description\":\"Enter the referring provider’s non-NPI identification number corresponding to the qualifier in Item 17a.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"4077\",\"name\":\"Referring provider NPI (17b)\",\"description\":\"Enter the referring provider’s National Provider Identifier (NPI).\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Hospitalization Dates (Item 18)\",\"fields\":[{\"id\":\"ad\",\"name\":\"Hospitalization From - Month\",\"description\":\"Enter the month the hospitalization began (FROM date).\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"a0\",\"name\":\"Hospitalization From - Day\",\"description\":\"Enter the day of the month the hospitalization began (FROM date).\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"1b\",\"name\":\"Hospitalization From - Year\",\"description\":\"Enter the year the hospitalization began (FROM date).\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"9b\",\"name\":\"Hospitalization To - Month\",\"description\":\"Enter the month the hospitalization ended (TO date). Fill only if 'Hospitalization From - Day' is 'Yes'.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\",\"depends_on\":[\"a0\"]},{\"id\":\"4f\",\"name\":\"Hospitalization To - Day\",\"description\":\"Enter the day of the month the hospitalization ended (TO date).\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"42\",\"name\":\"Hospitalization To - Year\",\"description\":\"Enter the year the hospitalization ended (TO date).\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Additional Claim Info & Outside Lab (Items 19-20)\",\"fields\":[{\"id\":\"1184\",\"name\":\"Additional Claim Information\",\"description\":\"Enter any additional claim information or remarks designated by NUCC that apply to this claim.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"3c72\",\"name\":\"Outside Lab: Yes\",\"description\":\"Check this box if the lab work for this claim was performed by an outside (non-office) laboratory.\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"9e41\",\"name\":\"Outside Lab: No\",\"description\":\"Check this box if the lab work for this claim was not performed by an outside laboratory.\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"96d6\",\"name\":\"Outside Lab Indicator\",\"description\":\"Indicate whether the services were performed by an outside laboratory (e.g., enter Yes or No).\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"064b\",\"name\":\"Outside Lab Charges\",\"description\":\"Enter the total charges amount for services performed by an outside laboratory.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Diagnosis Information (Item 21)\",\"fields\":[{\"id\":\"fc5b\",\"name\":\"ICD Indicator\",\"description\":\"Enter the ICD code set indicator that applies to the diagnosis codes listed (as required by the form).\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"928e\",\"name\":\"Diagnosis Code A\",\"description\":\"Enter the primary diagnosis code (A) describing the patient’s illness or injury.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"fa3c\",\"name\":\"Diagnosis Code B\",\"description\":\"Enter diagnosis code B describing the patient’s illness or injury.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"cd3a\",\"name\":\"Diagnosis Code C\",\"description\":\"Enter diagnosis code C describing the patient’s illness or injury.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"5abe\",\"name\":\"Diagnosis Code D\",\"description\":\"Enter diagnosis code D describing the patient’s illness or injury.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"c2f7\",\"name\":\"Diagnosis Code E\",\"description\":\"Enter diagnosis code E describing the patient’s illness or injury.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"4d20\",\"name\":\"Diagnosis Code F\",\"description\":\"Enter diagnosis code F describing the patient’s illness or injury.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"78d2\",\"name\":\"Diagnosis Code G\",\"description\":\"Enter diagnosis code G describing the patient’s illness or injury.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"7680\",\"name\":\"Diagnosis Code H\",\"description\":\"Enter diagnosis code H describing the patient’s illness or injury.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"0de6\",\"name\":\"Diagnosis Code I\",\"description\":\"Enter diagnosis code I describing the patient’s illness or injury.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"1014\",\"name\":\"Diagnosis Code J\",\"description\":\"Enter diagnosis code J describing the patient’s illness or injury.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"e256\",\"name\":\"Diagnosis Code K\",\"description\":\"Enter diagnosis code K describing the patient’s illness or injury.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"f649\",\"name\":\"Diagnosis Code L\",\"description\":\"Enter diagnosis code L describing the patient’s illness or injury.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"547d\",\"name\":\"Diagnosis Code M\",\"description\":\"Enter an additional diagnosis code (M) describing the patient’s illness or injury, if applicable.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Resubmission & Original Reference (Item 22)\",\"fields\":[{\"id\":\"6c38\",\"name\":\"Resubmission Code\",\"description\":\"Enter the code that indicates this claim is a resubmission or corrected/replacement claim, if applicable.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"8458\",\"name\":\"Original Reference Number\",\"description\":\"Enter the reference number or identifier for the original claim being resubmitted or corrected.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Prior Authorization Number (Item 23)\",\"fields\":[{\"id\":\"75fc\",\"name\":\"Prior Authorization Number\",\"description\":\"Enter the prior authorization number issued for the services being claimed (Item 23).\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"First Service Line (Item 24 - Row 1)\",\"fields\":[{\"id\":\"50\",\"name\":\"Service From Month\",\"description\":\"Enter the month of the start date of service for this service line.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"da\",\"name\":\"Service From Day\",\"description\":\"Enter the day of the start date of service for this service line.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"ec\",\"name\":\"Service From Year\",\"description\":\"Enter the year of the start date of service for this service line.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"fc\",\"name\":\"Service To Month\",\"description\":\"Enter the month of the end date of service for this service line, if applicable.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"98\",\"name\":\"Service To Day\",\"description\":\"Enter the day of the end date of service for this service line, if applicable.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"1a\",\"name\":\"Service To Year\",\"description\":\"Enter the year of the end date of service for this service line, if applicable.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"d235\",\"name\":\"Place of Service\",\"description\":\"Enter the place of service code that indicates where the service was provided.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"bdf8\",\"name\":\"Emergency Indicator\",\"description\":\"Enter the emergency indicator value for this service line, if required.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"859d\",\"name\":\"Procedure Code (CPT/HCPCS)\",\"description\":\"Enter the CPT or HCPCS procedure code for the service provided.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"2352\",\"name\":\"Modifier 1\",\"description\":\"Enter the first procedure modifier, if applicable.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"a7d9\",\"name\":\"Modifier 2\",\"description\":\"Enter the second procedure modifier, if applicable.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"1d5e\",\"name\":\"Modifier 3\",\"description\":\"Enter the third procedure modifier, if applicable.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"97bd\",\"name\":\"Modifier 4\",\"description\":\"Enter the fourth procedure modifier, if applicable.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"9384\",\"name\":\"Diagnosis Pointer\",\"description\":\"Enter the diagnosis code reference(s) (pointer) that apply to this procedure.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"e233\",\"name\":\"Line Item Charges\",\"description\":\"Enter the total charge amount for this service line.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"837a\",\"name\":\"Days or Units\",\"description\":\"Enter the number of days or units billed for this service line.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"e746\",\"name\":\"EPSDT/Family Plan\",\"description\":\"Enter the EPSDT or family planning indicator/code, if applicable.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"da0a\",\"name\":\"Rendering Provider ID Qualifier\",\"description\":\"Enter the qualifier that identifies the type of non-NPI rendering provider identifier being reported.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"5bb5\",\"name\":\"Rendering Provider NPI\",\"description\":\"Enter the rendering provider’s National Provider Identifier (NPI) for this service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"cb38\",\"name\":\"Row 1 — 24J Rendering Provider ID #\",\"description\":\"Enter the rendering provider's identifier for Row 1 (24J), for example the provider's NPI or other assigned ID.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"9909\",\"name\":\"Rendering Provider Other ID\",\"description\":\"Enter the rendering provider’s non-NPI identifier for this service line, if applicable.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Second Service Line (Item 24 - Row 2)\",\"fields\":[{\"id\":\"ac\",\"name\":\"Service Date From (Month)\",\"description\":\"Enter the month portion of the beginning date of service for the second service line.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"31\",\"name\":\"Service Date From (Day)\",\"description\":\"Enter the day portion of the beginning date of service for the second service line.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"ff\",\"name\":\"Service Date From (Year)\",\"description\":\"Enter the year portion of the beginning date of service for the second service line.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"cf\",\"name\":\"Service Date To (Month)\",\"description\":\"Enter the month portion of the ending date of service for the second service line.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"ca\",\"name\":\"Service Date To (Day)\",\"description\":\"Enter the day portion of the ending date of service for the second service line.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"3e\",\"name\":\"Service Date To (Year)\",\"description\":\"Enter the year portion of the ending date of service for the second service line.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"d2f1\",\"name\":\"Place of Service Code\",\"description\":\"Enter the place of service code that identifies where the services were provided for the second service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"03a8\",\"name\":\"Emergency Indicator (EMG)\",\"description\":\"Enter the emergency indicator value for the second service line, if applicable.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"173f\",\"name\":\"Procedure Code (CPT/HCPCS)\",\"description\":\"Enter the CPT or HCPCS procedure/service code for the second service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"aefb\",\"name\":\"Procedure Modifier 1\",\"description\":\"Enter the first procedure modifier associated with the procedure code for the second service line, if any.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"d526\",\"name\":\"Procedure Modifier 2\",\"description\":\"Enter the second procedure modifier associated with the procedure code for the second service line, if any.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"442e\",\"name\":\"Procedure Modifier 3\",\"description\":\"Enter the third procedure modifier associated with the procedure code for the second service line, if any.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"9441\",\"name\":\"Procedure Modifier 4\",\"description\":\"Enter the fourth procedure modifier associated with the procedure code for the second service line, if any.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"b021\",\"name\":\"Diagnosis Pointer\",\"description\":\"Enter the diagnosis pointer(s) that link this service to the relevant diagnosis code(s) for the second service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"a506\",\"name\":\"Line Item Charge Amount\",\"description\":\"Enter the total charge amount being billed for the second service line.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"14bd\",\"name\":\"Days or Units\",\"description\":\"Enter the number of days or units for the billed service on the second service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"81dd\",\"name\":\"EPSDT Indicator\",\"description\":\"Enter the EPSDT indicator value for the second service line, if applicable.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"b378\",\"name\":\"Family Planning Indicator\",\"description\":\"Enter the family planning indicator value for the second service line, if applicable.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"dbfc\",\"name\":\"Rendering Provider ID Qualifier\",\"description\":\"Enter the qualifier that identifies the type of rendering provider identifier reported for the second service line.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"cbfc\",\"name\":\"Rendering Provider NPI\",\"description\":\"Enter the rendering provider's NPI for the second service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"309c\",\"name\":\"Rendering Provider Other ID\",\"description\":\"Enter the rendering provider's other identifier (non-NPI), if applicable, for the second service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Third Service Line (Item 24 - Row 3)\",\"fields\":[{\"id\":\"aa\",\"name\":\"From Date of Service - Month\",\"description\":\"Enter the month of the start (FROM) date of service for this third service line.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"5b\",\"name\":\"From Date of Service - Day\",\"description\":\"Enter the day of the start (FROM) date of service for this third service line.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"c8\",\"name\":\"From Date of Service - Year\",\"description\":\"Enter the year of the start (FROM) date of service for this third service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"e6\",\"name\":\"To Date of Service - Month\",\"description\":\"Enter the month of the end (TO) date of service for this third service line, if different from the from date.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"ba\",\"name\":\"To Date of Service - Day\",\"description\":\"Enter the day of the end (TO) date of service for this third service line, if different from the from date.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"f0\",\"name\":\"To Date of Service - Year\",\"description\":\"Enter the year of the end (TO) date of service for this third service line, if different from the from date.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"aa1b\",\"name\":\"Place of Service\",\"description\":\"Enter the place of service code for where the service was performed on this third service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"ed8d\",\"name\":\"Emergency Indicator\",\"description\":\"Enter the emergency indicator for this third service line, if applicable.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"71e6\",\"name\":\"Procedure/Service Code (CPT/HCPCS)\",\"description\":\"Enter the CPT/HCPCS procedure or service code billed on this third service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"95b2\",\"name\":\"Modifier 1\",\"description\":\"Enter the first procedure modifier for the CPT/HCPCS code on this third service line, if applicable.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"98e7\",\"name\":\"Modifier 2\",\"description\":\"Enter the second procedure modifier for the CPT/HCPCS code on this third service line, if applicable.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"dcaa\",\"name\":\"Modifier 3\",\"description\":\"Enter the third procedure modifier for the CPT/HCPCS code on this third service line, if applicable.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"99ca\",\"name\":\"Modifier 4\",\"description\":\"Enter the fourth procedure modifier for the CPT/HCPCS code on this third service line, if applicable.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"db4c\",\"name\":\"Diagnosis Pointer\",\"description\":\"Enter the diagnosis code reference letter(s) (from Item 21) that apply to this third service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"179f\",\"name\":\"Charges - Dollars\",\"description\":\"Enter the dollar amount charged for this third service line.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"c6a4\",\"name\":\"Charges - Cents\",\"description\":\"Enter the cents portion of the amount charged for this third service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"df36\",\"name\":\"Days or Units\",\"description\":\"Enter the number of days or units for the service billed on this third service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"b799\",\"name\":\"EPSDT/Family Plan\",\"description\":\"Enter the EPSDT/Family Plan indicator for this third service line, if applicable.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"f3a5\",\"name\":\"Rendering Provider ID Qualifier\",\"description\":\"Enter the qualifier that identifies the type of non-NPI rendering provider identifier reported for this third service line, if applicable.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"9489\",\"name\":\"Rendering Provider NPI\",\"description\":\"Enter the rendering provider's NPI for this third service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"21ab\",\"name\":\"Rendering Provider Other ID\",\"description\":\"Enter the rendering provider's non-NPI identifier for this third service line, if applicable.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"fields\":[{\"id\":\"c3\",\"name\":\"Service Line 4 From Date (MM)\",\"description\":\"Enter the month of the start date for the service period on this service line.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"09\",\"name\":\"Service Line 4 From Date (DD)\",\"description\":\"Enter the day of the start date for the service period on this service line.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"6a\",\"name\":\"Service Line 4 From Date (YY)\",\"description\":\"Enter the two-digit year of the start date for the service period on this service line.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"cd\",\"name\":\"Service Line 4 To Date (MM)\",\"description\":\"Enter the month of the end date for the service period on this service line.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"54\",\"name\":\"Service Line 4 To Date (DD)\",\"description\":\"Enter the day of the end date for the service period on this service line.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"89\",\"name\":\"Service Line 4 To Date (YY)\",\"description\":\"Enter the two-digit year of the end date for the service period on this service line.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"7e1a\",\"name\":\"Service Line 4 Place of Service\",\"description\":\"Enter the place of service code that describes where the service was provided for this service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"4d66\",\"name\":\"Service Line 4 Emergency Indicator\",\"description\":\"Enter the emergency indicator value for this service line, if applicable.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"ebff\",\"name\":\"Service Line 4 Procedure Code (CPT/HCPCS)\",\"description\":\"Enter the CPT/HCPCS procedure code for the service or item billed on this service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"80ca\",\"name\":\"Service Line 4 Modifier 1\",\"description\":\"Enter the first procedure modifier associated with the billed procedure code on this service line, if any.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"294f\",\"name\":\"Service Line 4 Modifier 2\",\"description\":\"Enter the second procedure modifier associated with the billed procedure code on this service line, if any.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"471d\",\"name\":\"Service Line 4 Modifier 3\",\"description\":\"Enter the third procedure modifier associated with the billed procedure code on this service line, if any.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"8ca2\",\"name\":\"Service Line 4 Modifier 4\",\"description\":\"Enter the fourth procedure modifier associated with the billed procedure code on this service line, if any.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"8fef\",\"name\":\"Service Line 4 Diagnosis Pointer\",\"description\":\"Enter the diagnosis pointer(s) that link this service line to the diagnosis code(s) listed in the diagnosis section.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"4a0b\",\"name\":\"Service Line 4 Charges\",\"description\":\"Enter the total charge amount being billed for this service line.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"b01e\",\"name\":\"Service Line 4 Days or Units\",\"description\":\"Enter the number of days or units for the service billed on this service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"a940\",\"name\":\"Service Line 4 EPSDT/Family Plan\",\"description\":\"Enter the EPSDT or family planning indicator for this service line, if applicable.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"6c47\",\"name\":\"Service Line 4 Provider ID Qualifier\",\"description\":\"Enter the qualifier that identifies the type of provider ID reported for this service line, if applicable.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"ec00\",\"name\":\"Service Line 4 Rendering Provider ID (Non-NPI)\",\"description\":\"Enter the rendering provider's non-NPI identifier for this service line, if required by the payer.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"6523\",\"name\":\"Service Line 4 Rendering Provider NPI\",\"description\":\"Enter the rendering provider's National Provider Identifier (NPI) for this service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"3d98\",\"name\":\"Service Line 4 Rendering Provider NPI (Alternate Box)\",\"description\":\"Enter the rendering provider's National Provider Identifier (NPI) for this service line if the form uses this second identifier box.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"fields\":[{\"id\":\"9f\",\"name\":\"From Date of Service - Month\",\"description\":\"Enter the month portion of the start date for this fifth service line.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"32\",\"name\":\"From Date of Service - Day\",\"description\":\"Enter the day portion of the start date for this fifth service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"7c\",\"name\":\"From Date of Service - Year\",\"description\":\"Enter the year portion of the start date for this fifth service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"e2\",\"name\":\"To Date of Service - Month\",\"description\":\"Enter the month portion of the end date for this fifth service line (if different from the from date).\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"4c\",\"name\":\"To Date of Service - Day\",\"description\":\"Enter the day portion of the end date for this fifth service line (if different from the from date).\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"af\",\"name\":\"To Date of Service - Year\",\"description\":\"Enter the year portion of the end date for this fifth service line (if different from the from date).\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"9c64\",\"name\":\"Place of Service\",\"description\":\"Enter the place of service code for where the service was provided on this fifth service line.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"e465\",\"name\":\"Emergency Indicator (EMG)\",\"description\":\"Enter the emergency indicator value for this fifth service line, if applicable.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"35b7\",\"name\":\"Procedure/Service Code (CPT/HCPCS)\",\"description\":\"Enter the CPT/HCPCS procedure or service code for this fifth service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"940d\",\"name\":\"Modifier 1\",\"description\":\"Enter the first procedure modifier associated with the CPT/HCPCS code on this fifth service line, if any.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"3818\",\"name\":\"Modifier 2\",\"description\":\"Enter the second procedure modifier associated with the CPT/HCPCS code on this fifth service line, if any.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"ce7f\",\"name\":\"Modifier 3\",\"description\":\"Enter the third procedure modifier associated with the CPT/HCPCS code on this fifth service line, if any.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"af91\",\"name\":\"Modifier 4\",\"description\":\"Enter the fourth procedure modifier associated with the CPT/HCPCS code on this fifth service line, if any.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"5b52\",\"name\":\"Diagnosis Pointer\",\"description\":\"Enter the diagnosis pointer(s) (letters/numbers that reference the diagnoses listed in Item 21) that apply to this fifth service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"ffc4\",\"name\":\"Line Item Charges\",\"description\":\"Enter the charge amount billed for this fifth service line.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"efee\",\"name\":\"Days or Units\",\"description\":\"Enter the number of days or units for the service billed on this fifth service line.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"bd46\",\"name\":\"EPSDT Indicator\",\"description\":\"Enter the EPSDT indicator value for this fifth service line, if applicable.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"1446\",\"name\":\"Family Plan Indicator\",\"description\":\"Enter the family plan indicator value for this fifth service line, if applicable.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"9545\",\"name\":\"Rendering Provider ID Qualifier\",\"description\":\"Enter the qualifier that identifies the type of rendering provider ID reported for this fifth service line.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"0da7\",\"name\":\"Rendering Provider ID (Non-NPI)\",\"description\":\"Enter the rendering provider's non-NPI identifier for this fifth service line, if required.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"3922\",\"name\":\"Rendering Provider NPI\",\"description\":\"Enter the rendering provider's National Provider Identifier (NPI) for this fifth service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"fields\":[{\"id\":\"0c\",\"name\":\"Service Line 6 From Date (Month)\",\"description\":\"Enter the month of the beginning date of service for the sixth service line.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"18\",\"name\":\"Service Line 6 From Date (Day)\",\"description\":\"Enter the day of the beginning date of service for the sixth service line.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"23\",\"name\":\"Service Line 6 From Date (Year)\",\"description\":\"Enter the year of the beginning date of service for the sixth service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"61\",\"name\":\"Service Line 6 To Date (Month)\",\"description\":\"Enter the month of the ending date of service for the sixth service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"d9\",\"name\":\"Service Line 6 To Date (Day)\",\"description\":\"Enter the day of the ending date of service for the sixth service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"13\",\"name\":\"Service Line 6 To Date (Year)\",\"description\":\"Enter the year of the ending date of service for the sixth service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"form_max_length\":2,\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"2101\",\"name\":\"Service Line 6 Place of Service Code\",\"description\":\"Enter the place of service code that identifies where the service was provided for the sixth service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"deb5\",\"name\":\"Service Line 6 EMG Indicator\",\"description\":\"Enter the emergency indicator value for the sixth service line, if applicable.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"4399\",\"name\":\"Service Line 6 CPT/HCPCS Code\",\"description\":\"Enter the CPT or HCPCS procedure code for the service billed on the sixth service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"675d\",\"name\":\"Service Line 6 Modifier 1\",\"description\":\"Enter the first procedure modifier that applies to the CPT/HCPCS code on the sixth service line, if any.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"a0d0\",\"name\":\"Service Line 6 Modifier 2\",\"description\":\"Enter the second procedure modifier that applies to the CPT/HCPCS code on the sixth service line, if any.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"c3ce\",\"name\":\"Service Line 6 Modifier 3\",\"description\":\"Enter the third procedure modifier that applies to the CPT/HCPCS code on the sixth service line, if any.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"2c24\",\"name\":\"Service Line 6 Modifier 4\",\"description\":\"Enter the fourth procedure modifier that applies to the CPT/HCPCS code on the sixth service line, if any.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"1335\",\"name\":\"Service Line 6 Diagnosis Pointer\",\"description\":\"Enter the diagnosis reference letter(s)/number(s) that link this service to the diagnoses listed in Item 21.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"0825\",\"name\":\"Service Line 6 Charge Amount\",\"description\":\"Enter the total charge amount being billed for the sixth service line.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"02d9\",\"name\":\"Service Line 6 Days or Units\",\"description\":\"Enter the number of days or units for the service billed on the sixth service line.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"699d\",\"name\":\"Service Line 6 EPSDT Indicator\",\"description\":\"Enter the EPSDT indicator value for the sixth service line, if applicable.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"4007\",\"name\":\"Service Line 6 Family Plan Indicator\",\"description\":\"Enter the family plan indicator value for the sixth service line, if applicable.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"cf33\",\"name\":\"Service Line 6 Rendering Provider ID Qualifier\",\"description\":\"Enter the qualifier that identifies the type of non-NPI rendering provider identifier reported for the sixth service line, if applicable.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"6a4f\",\"name\":\"Service Line 6 Rendering Provider Other ID\",\"description\":\"Enter the rendering provider’s non-NPI identifier for the sixth service line, if applicable.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"6cc1\",\"name\":\"Service Line 6 Rendering Provider NPI\",\"description\":\"Enter the rendering provider’s NPI for the sixth service line.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Tax ID, Patient Account & Claim Totals (Items 25-30)\",\"fields\":[{\"id\":\"804b\",\"name\":\"Federal Tax ID Number\",\"description\":\"Enter the billing provider’s Federal Tax Identification Number (TIN).\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"66c9\",\"name\":\"Federal Tax ID Type: SSN\",\"description\":\"Check this box if the Federal Tax ID number entered in Item 25 is a Social Security Number (SSN).\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"9b09\",\"name\":\"Federal Tax ID Type: EIN\",\"description\":\"Check this box if the Federal Tax ID number entered in Item 25 is an Employer Identification Number (EIN).\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"acf9\",\"name\":\"Patient Account Number\",\"description\":\"Enter the patient’s account number used by the provider or facility to identify this claim.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"00d0\",\"name\":\"Accept Assignment: Yes\",\"description\":\"Check this box if the provider accepts assignment of benefits for this claim.\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"3c21\",\"name\":\"Accept Assignment: No\",\"description\":\"Check this box if the provider does not accept assignment of benefits for this claim.\",\"form_type\":\"Checkbox\",\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"7912\",\"name\":\"Total Charge\",\"description\":\"Enter the total charges for all services reported on this claim.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"0942\",\"name\":\"Amount Paid\",\"description\":\"Enter the amount already paid toward this claim by the patient and/or other sources.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"8a93\",\"name\":\"Reserved for NUCC Use (Part 1)\",\"description\":\"Enter any information required by NUCC or the payer for the first reserved segment of Item 30.\",\"form_type\":\"Number\",\"allowed_types\":[\"Number\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"cfa2\",\"name\":\"Reserved for NUCC Use (Part 2)\",\"description\":\"Enter any information required by NUCC or the payer for the second reserved segment of Item 30.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"67b2\",\"name\":\"Reserved for NUCC Use (Part 3)\",\"description\":\"Enter any information required by NUCC or the payer for the third reserved segment of Item 30.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"d6c9\",\"name\":\"Reserved for NUCC Use (Part 4)\",\"description\":\"Enter any information required by NUCC or the payer for the fourth reserved segment of Item 30.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Physician/Supplier Signature (Item 31)\",\"fields\":[{\"id\":\"42e1\",\"name\":\"Physician/Supplier Signature\",\"description\":\"Enter the signature of the physician or supplier (including degrees or credentials) certifying the claim.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"2869\",\"name\":\"Signature Date\",\"description\":\"Enter the date the physician or supplier signed the claim.\",\"form_type\":\"Date\",\"allowed_types\":[\"Date\",\"Text\"],\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Service Facility Location (Item 32)\",\"fields\":[{\"id\":\"2240\",\"name\":\"Service Facility Name and Address\",\"description\":\"Enter the name and full address of the facility where the services were provided (street, city, state, and ZIP code).\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"3384\",\"name\":\"Service Facility NPI\",\"description\":\"Enter the National Provider Identifier (NPI) for the service facility.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"fe11\",\"name\":\"Service Facility Other ID\",\"description\":\"Enter any additional identification number for the service facility (if applicable).\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"}]},{\"group\":\"Billing Provider Info & Phone (Item 33)\",\"fields\":[{\"id\":\"6af1\",\"name\":\"Billing Provider Phone Area Code\",\"description\":\"Enter the area code portion of the billing provider’s phone number.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"1114\",\"name\":\"Billing Provider Phone Number\",\"description\":\"Enter the remaining digits of the billing provider’s phone number.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"7a94\",\"name\":\"Billing Provider Name and Address\",\"description\":\"Enter the billing provider’s name and mailing address (and other identifying details as needed) as shown in Item 33.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"c1a7\",\"name\":\"Billing Provider NPI (33a)\",\"description\":\"Enter the billing provider’s National Provider Identifier (NPI).\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"},{\"id\":\"650f\",\"name\":\"Billing Provider Other ID (33b)\",\"description\":\"Enter the billing provider’s other identifier (if applicable) as required by the payer.\",\"form_type\":\"Text\",\"allowed_types\":[\"Text\",\"Number\",\"Date\",\"Time\"],\"page_num\":0,\"section\":\"Page 1\"}]}]}},\"sourceToolAssistantUUID\":\"ac80c794-43f0-4772-9c27-aa1d5b08e0d9\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"c:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"type\":\"last-prompt\",\"lastPrompt\":\"Find the Insured Phone Number field and change its type to text since the field was filled in inappropriate format: TELEPHONE (Include Area Code) - +1 (614) 5,550,192 It must be +1 (614) 555-0192\",\"leafUuid\":\"c44a7285-bb96-4c15-96f4-d9f1ef74dfec\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\"}\n{\"type\":\"ai-title\",\"aiTitle\":\"View available workspace forms\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\"}\n{\"parentUuid\":\"c44a7285-bb96-4c15-96f4-d9f1ef74dfec\",\"isSidechain\":false,\"message\":{\"model\":\"claude-opus-4-8\",\"id\":\"msg_012BRCX1ma7TRpcF5steo7Hm\",\"type\":\"message\",\"role\":\"assistant\",\"content\":[{\"type\":\"thinking\",\"thinking\":\"\",\"signature\":\"EoMCCmMIDhgCKkBEDfLgLixrrpsgettafgvJE3L3qI1tAL+I77wb6Mu9REDqzAamtRBnRu3rPatO2tMiFZKcVW16RjxCOHuAuD+4Mg9jbGF1ZGUtb3B1cy00LTg4AEIIdGhpbmtpbmcSDEZ0QT3SNxnJ+4BQthoMT8c7qUnvq1PHzw3QIjC2SAFnqP/gD9VjL7HuG+0DSaKCrwjU+DJPuEWvaMGZf1Ajr1/9S/Ty7lvxO/S+xkYqTk5Go5JvNsBP7NVlYVgWe0iQp7U13D73No80eoXd1cHyFnh1Z0o+Dt9NR4kkk0T9EZXHHeE6FZdwfTdNEta+53sM16qBX6mmUGCbN/hGThgB\"}],\"stop_reason\":\"tool_use\",\"stop_sequence\":null,\"stop_details\":null,\"usage\":{\"input_tokens\":2,\"cache_creation_input_tokens\":758,\"cache_read_input_tokens\":45705,\"output_tokens\":330,\"server_tool_use\":{\"web_search_requests\":0,\"web_fetch_requests\":0},\"service_tier\":\"standard\",\"cache_creation\":{\"ephemeral_1h_input_tokens\":758,\"ephemeral_5m_input_tokens\":0},\"inference_geo\":\"not_available\",\"iterations\":[{\"input_tokens\":2,\"output_tokens\":330,\"cache_read_input_tokens\":45705,\"cache_creation_input_tokens\":758,\"cache_creation\":{\"ephemeral_5m_input_tokens\":0,\"ephemeral_1h_input_tokens\":758},\"type\":\"message\"}],\"speed\":\"standard\"},\"diagnostics\":null},\"requestId\":\"req_011Cc7Puv9KcXdLabq6LzTq5\",\"attributionMcpServer\":\"claude.ai Instafill\",\"attributionMcpTool\":\"get_form_fields\",\"type\":\"assistant\",\"uuid\":\"0f3177dd-e9e8-4fc9-acd8-ba822cba7010\",\"timestamp\":\"2026-06-16T18:16:06.118Z\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"c:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"parentUuid\":\"0f3177dd-e9e8-4fc9-acd8-ba822cba7010\",\"isSidechain\":false,\"message\":{\"model\":\"claude-opus-4-8\",\"id\":\"msg_012BRCX1ma7TRpcF5steo7Hm\",\"type\":\"message\",\"role\":\"assistant\",\"content\":[{\"type\":\"text\",\"text\":\"The output was large; let me query it directly for the insured phone field.\"}],\"stop_reason\":\"tool_use\",\"stop_sequence\":null,\"stop_details\":null,\"usage\":{\"input_tokens\":2,\"cache_creation_input_tokens\":758,\"cache_read_input_tokens\":45705,\"output_tokens\":330,\"server_tool_use\":{\"web_search_requests\":0,\"web_fetch_requests\":0},\"service_tier\":\"standard\",\"cache_creation\":{\"ephemeral_1h_input_tokens\":758,\"ephemeral_5m_input_tokens\":0},\"inference_geo\":\"not_available\",\"iterations\":[{\"input_tokens\":2,\"output_tokens\":330,\"cache_read_input_tokens\":45705,\"cache_creation_input_tokens\":758,\"cache_creation\":{\"ephemeral_5m_input_tokens\":0,\"ephemeral_1h_input_tokens\":758},\"type\":\"message\"}],\"speed\":\"standard\"},\"diagnostics\":null},\"requestId\":\"req_011Cc7Puv9KcXdLabq6LzTq5\",\"attributionMcpServer\":\"claude.ai Instafill\",\"attributionMcpTool\":\"get_form_fields\",\"type\":\"assistant\",\"uuid\":\"32ef4350-c52c-4457-a3aa-769781dd7f70\",\"timestamp\":\"2026-06-16T18:16:06.667Z\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"c:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"parentUuid\":\"32ef4350-c52c-4457-a3aa-769781dd7f70\",\"isSidechain\":false,\"message\":{\"model\":\"claude-opus-4-8\",\"id\":\"msg_012BRCX1ma7TRpcF5steo7Hm\",\"type\":\"message\",\"role\":\"assistant\",\"content\":[{\"type\":\"tool_use\",\"id\":\"toolu_01KZfjstpS9aD6UZ8sJomE6X\",\"name\":\"Bash\",\"input\":{\"command\":\"jq -c '.groups[].fields[]? | select((.name//\\\"\\\" | test(\\\"phone|telephone\\\";\\\"i\\\")) or (.description//\\\"\\\" | test(\\\"phone|telephone\\\";\\\"i\\\"))) | {id, name, form_type, allowed_types, section, group, max_length}' \\\"C:\\\\Users\\\\smirn\\\\.claude\\\\projects\\\\c--Users-smirn-OneDrive-Documents-GitHub-botmakers-projects-copilot-us-instafill-ai\\\\986638d6-b238-4e02-83a0-449ec3df5830\\\\tool-results\\\\mcp-claude_ai_Instafill-get_form_fields-1781633763810.txt\\\"\",\"description\":\"Find phone/telephone fields in form fields JSON\"},\"caller\":{\"type\":\"direct\"}}],\"stop_reason\":\"tool_use\",\"stop_sequence\":null,\"stop_details\":null,\"usage\":{\"input_tokens\":2,\"cache_creation_input_tokens\":758,\"cache_read_input_tokens\":45705,\"output_tokens\":330,\"server_tool_use\":{\"web_search_requests\":0,\"web_fetch_requests\":0},\"service_tier\":\"standard\",\"cache_creation\":{\"ephemeral_1h_input_tokens\":758,\"ephemeral_5m_input_tokens\":0},\"inference_geo\":\"not_available\",\"iterations\":[{\"input_tokens\":2,\"output_tokens\":330,\"cache_read_input_tokens\":45705,\"cache_creation_input_tokens\":758,\"cache_creation\":{\"ephemeral_5m_input_tokens\":0,\"ephemeral_1h_input_tokens\":758},\"type\":\"message\"}],\"speed\":\"standard\"},\"diagnostics\":null},\"requestId\":\"req_011Cc7Puv9KcXdLabq6LzTq5\",\"attributionMcpServer\":\"claude.ai Instafill\",\"attributionMcpTool\":\"get_form_fields\",\"type\":\"assistant\",\"uuid\":\"90f5c939-82bd-4fdd-bdf0-e98c607e54b0\",\"timestamp\":\"2026-06-16T18:16:09.252Z\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"c:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"parentUuid\":\"90f5c939-82bd-4fdd-bdf0-e98c607e54b0\",\"isSidechain\":false,\"promptId\":\"6301aad3-e064-44e4-8397-fa03af66d65d\",\"type\":\"user\",\"message\":{\"role\":\"user\",\"content\":[{\"type\":\"tool_result\",\"content\":\"Exit code 127\\n/usr/bin/bash: line 1: jq: command not found\",\"is_error\":true,\"tool_use_id\":\"toolu_01KZfjstpS9aD6UZ8sJomE6X\"}]},\"uuid\":\"ee866c0d-85f1-4a98-9e4e-29cce6d2cab1\",\"timestamp\":\"2026-06-16T18:16:29.785Z\",\"toolUseResult\":\"Error: Exit code 127\\n/usr/bin/bash: line 1: jq: command not found\",\"sourceToolAssistantUUID\":\"90f5c939-82bd-4fdd-bdf0-e98c607e54b0\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"c:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"parentUuid\":\"ee866c0d-85f1-4a98-9e4e-29cce6d2cab1\",\"isSidechain\":false,\"message\":{\"model\":\"claude-opus-4-8\",\"id\":\"msg_013Up34emknGYGyLCvavpMnA\",\"type\":\"message\",\"role\":\"assistant\",\"content\":[{\"type\":\"thinking\",\"thinking\":\"\",\"signature\":\"EqoCCmMIDhgCKkAogT12pI3Xq3S4l1xqG+lta6JTjP5QxWtKMsFkcQol+ZtSGmk29pokA8M49+q4OqZKDwBeVmoG/x/yq7RUCm2AMg9jbGF1ZGUtb3B1cy00LTg4AEIIdGhpbmtpbmcSDHUAKwQcgmltrfIAHRoMeLYklQi5sYXlPQ9EIjA7MEW/xGzjDLTy0a17dildO8uAVvB+dn+KNaMFs60EUUcibaQbYLSBZ61ITz8hojAqdWMVISx0Lg0j1jK2iwc6aY67owNvkSp2konp2QaaRKw8fFuE1mFwlq0JMiDtcNU3My6Aq2DaKqgMqG4cS0HIIPHhH8H122gmbHli53vWjdEV1fbIrC1yaK6txMtV+0gYom2mHbe1E+YZJqfTl++eoI8QMcro4xgB\"}],\"stop_reason\":\"tool_use\",\"stop_sequence\":null,\"stop_details\":null,\"usage\":{\"input_tokens\":2,\"cache_creation_input_tokens\":368,\"cache_read_input_tokens\":46463,\"output_tokens\":397,\"server_tool_use\":{\"web_search_requests\":0,\"web_fetch_requests\":0},\"service_tier\":\"standard\",\"cache_creation\":{\"ephemeral_1h_input_tokens\":368,\"ephemeral_5m_input_tokens\":0},\"inference_geo\":\"not_available\",\"iterations\":[{\"input_tokens\":2,\"output_tokens\":397,\"cache_read_input_tokens\":46463,\"cache_creation_input_tokens\":368,\"cache_creation\":{\"ephemeral_5m_input_tokens\":0,\"ephemeral_1h_input_tokens\":368},\"type\":\"message\"}],\"speed\":\"standard\"},\"diagnostics\":null},\"requestId\":\"req_011Cc7Pwq4nYUr4RgLtYiwf2\",\"attributionMcpServer\":\"claude.ai Instafill\",\"attributionMcpTool\":\"get_form_fields\",\"type\":\"assistant\",\"uuid\":\"8878e920-19af-408e-8367-28711e98539f\",\"timestamp\":\"2026-06-16T18:16:32.692Z\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"c:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"parentUuid\":\"8878e920-19af-408e-8367-28711e98539f\",\"isSidechain\":false,\"message\":{\"model\":\"claude-opus-4-8\",\"id\":\"msg_013Up34emknGYGyLCvavpMnA\",\"type\":\"message\",\"role\":\"assistant\",\"content\":[{\"type\":\"tool_use\",\"id\":\"toolu_013T2mtmTSkE7up8MhyPv3BD\",\"name\":\"Bash\",\"input\":{\"command\":\"python -c \\\"\\nimport json,re\\np=r'C:\\\\Users\\\\smirn\\\\.claude\\\\projects\\\\c--Users-smirn-OneDrive-Documents-GitHub-botmakers-projects-copilot-us-instafill-ai\\\\986638d6-b238-4e02-83a0-449ec3df5830\\\\tool-results\\\\mcp-claude_ai_Instafill-get_form_fields-1781633763810.txt'\\nd=json.load(open(p,encoding='utf-8'))\\nfor g in d['groups']:\\n for f in g.get('fields',[]):\\n t=(f.get('name','') or '')+' '+(f.get('description','') or '')\\n if re.search('phone|telephone',t,re.I):\\n print(json.dumps({k:f.get(k) for k in ('id','name','form_type','allowed_types','section','group','max_length')},ensure_ascii=False))\\n\\\"\",\"description\":\"Find phone fields via python\"},\"caller\":{\"type\":\"direct\"}}],\"stop_reason\":\"tool_use\",\"stop_sequence\":null,\"stop_details\":null,\"usage\":{\"input_tokens\":2,\"cache_creation_input_tokens\":368,\"cache_read_input_tokens\":46463,\"output_tokens\":397,\"server_tool_use\":{\"web_search_requests\":0,\"web_fetch_requests\":0},\"service_tier\":\"standard\",\"cache_creation\":{\"ephemeral_1h_input_tokens\":368,\"ephemeral_5m_input_tokens\":0},\"inference_geo\":\"not_available\",\"iterations\":[{\"input_tokens\":2,\"output_tokens\":397,\"cache_read_input_tokens\":46463,\"cache_creation_input_tokens\":368,\"cache_creation\":{\"ephemeral_5m_input_tokens\":0,\"ephemeral_1h_input_tokens\":368},\"type\":\"message\"}],\"speed\":\"standard\"},\"diagnostics\":null},\"requestId\":\"req_011Cc7Pwq4nYUr4RgLtYiwf2\",\"attributionMcpServer\":\"claude.ai 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\\\"max_length\\\": null}\\r\\n{\\\"id\\\": \\\"00c3\\\", \\\"name\\\": \\\"Patient Telephone Number\\\", \\\"form_type\\\": \\\"Text\\\", \\\"allowed_types\\\": [\\\"Text\\\", \\\"Number\\\", \\\"Date\\\", \\\"Time\\\"], \\\"section\\\": \\\"Page 1\\\", \\\"group\\\": null, \\\"max_length\\\": null}\\r\\n{\\\"id\\\": \\\"d7f2\\\", \\\"name\\\": \\\"Insured Phone Area Code\\\", \\\"form_type\\\": \\\"Text\\\", \\\"allowed_types\\\": [\\\"Text\\\", \\\"Number\\\", \\\"Date\\\", \\\"Time\\\"], \\\"section\\\": \\\"Page 1\\\", \\\"group\\\": null, \\\"max_length\\\": null}\\r\\n{\\\"id\\\": \\\"f653\\\", \\\"name\\\": \\\"Insured Phone Number\\\", \\\"form_type\\\": \\\"Number\\\", \\\"allowed_types\\\": [\\\"Number\\\", \\\"Text\\\"], \\\"section\\\": \\\"Page 1\\\", \\\"group\\\": null, \\\"max_length\\\": null}\\r\\n{\\\"id\\\": \\\"6af1\\\", \\\"name\\\": \\\"Billing Provider Phone Area Code\\\", \\\"form_type\\\": \\\"Text\\\", \\\"allowed_types\\\": [\\\"Text\\\", \\\"Number\\\", \\\"Date\\\", \\\"Time\\\"], \\\"section\\\": \\\"Page 1\\\", \\\"group\\\": null, \\\"max_length\\\": null}\\r\\n{\\\"id\\\": \\\"1114\\\", \\\"name\\\": \\\"Billing Provider Phone Number\\\", \\\"form_type\\\": \\\"Text\\\", \\\"allowed_types\\\": [\\\"Text\\\", \\\"Number\\\", \\\"Date\\\", \\\"Time\\\"], \\\"section\\\": \\\"Page 1\\\", \\\"group\\\": null, \\\"max_length\\\": null}\",\"is_error\":false}]},\"uuid\":\"8261010c-a2a3-4b43-a5f8-e8add566be87\",\"timestamp\":\"2026-06-16T18:16:44.491Z\",\"toolUseResult\":{\"stdout\":\"{\\\"id\\\": \\\"8942\\\", \\\"name\\\": \\\"Patient Telephone (Area Code)\\\", \\\"form_type\\\": \\\"Text\\\", \\\"allowed_types\\\": [\\\"Text\\\", \\\"Number\\\", \\\"Date\\\", \\\"Time\\\"], \\\"section\\\": \\\"Page 1\\\", \\\"group\\\": null, \\\"max_length\\\": null}\\r\\n{\\\"id\\\": \\\"00c3\\\", \\\"name\\\": \\\"Patient Telephone Number\\\", \\\"form_type\\\": \\\"Text\\\", \\\"allowed_types\\\": [\\\"Text\\\", \\\"Number\\\", \\\"Date\\\", \\\"Time\\\"], \\\"section\\\": \\\"Page 1\\\", \\\"group\\\": null, \\\"max_length\\\": null}\\r\\n{\\\"id\\\": \\\"d7f2\\\", \\\"name\\\": \\\"Insured Phone Area Code\\\", \\\"form_type\\\": \\\"Text\\\", \\\"allowed_types\\\": [\\\"Text\\\", \\\"Number\\\", \\\"Date\\\", \\\"Time\\\"], \\\"section\\\": \\\"Page 1\\\", \\\"group\\\": null, \\\"max_length\\\": null}\\r\\n{\\\"id\\\": \\\"f653\\\", \\\"name\\\": \\\"Insured Phone Number\\\", \\\"form_type\\\": \\\"Number\\\", \\\"allowed_types\\\": [\\\"Number\\\", \\\"Text\\\"], \\\"section\\\": \\\"Page 1\\\", \\\"group\\\": null, \\\"max_length\\\": null}\\r\\n{\\\"id\\\": \\\"6af1\\\", \\\"name\\\": \\\"Billing Provider Phone Area Code\\\", \\\"form_type\\\": \\\"Text\\\", \\\"allowed_types\\\": [\\\"Text\\\", \\\"Number\\\", \\\"Date\\\", \\\"Time\\\"], \\\"section\\\": \\\"Page 1\\\", \\\"group\\\": null, \\\"max_length\\\": null}\\r\\n{\\\"id\\\": \\\"1114\\\", \\\"name\\\": \\\"Billing Provider Phone Number\\\", \\\"form_type\\\": \\\"Text\\\", \\\"allowed_types\\\": [\\\"Text\\\", \\\"Number\\\", \\\"Date\\\", \\\"Time\\\"], \\\"section\\\": \\\"Page 1\\\", \\\"group\\\": null, \\\"max_length\\\": null}\",\"stderr\":\"\",\"interrupted\":false,\"isImage\":false,\"noOutputExpected\":false},\"sourceToolAssistantUUID\":\"9af2dfee-91b8-4d27-b076-251e4a3cf13c\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"C:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"parentUuid\":\"8261010c-a2a3-4b43-a5f8-e8add566be87\",\"isSidechain\":false,\"attachment\":{\"type\":\"todo_reminder\",\"content\":[],\"itemCount\":0},\"type\":\"attachment\",\"uuid\":\"5ee55e5e-28e7-4f7c-a170-89a7095b91c2\",\"timestamp\":\"2026-06-16T18:16:44.502Z\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"C:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"parentUuid\":\"5ee55e5e-28e7-4f7c-a170-89a7095b91c2\",\"isSidechain\":false,\"message\":{\"model\":\"claude-opus-4-8\",\"id\":\"msg_01EvBHUKrMKpe2radzKJQtTd\",\"type\":\"message\",\"role\":\"assistant\",\"content\":[{\"type\":\"thinking\",\"thinking\":\"\",\"signature\":\"Eu8CCmMIDhgCKkAjnIvsYrPlcqqTxa66e7UUNYR2PXRZMeK9LYNp3zr5DEfu4Jf4mrdmtWE7+Pf/g8I+hBihHRdWoP25Xqx2+xuYMg9jbGF1ZGUtb3B1cy00LTg4AEIIdGhpbmtpbmcSDGnF5zpvEfS9FheEYhoMV72MJekDxf/7tL/uIjCgpTLMiENDf2i4/yJgysMFnNpmlbXFjkkFR33IkvXATMXAynFKffb0iM/BVnutnBQquQHtZ9VUFXzv5RFt8XJ0jSVeGPKroR7vft3OnyETLpSCwhn6bsB0Z5I0FpYJeGIyn5GZwGzR641Gg+m3opOWA8sf1ZKbHROYS44KFfYzHiLAfbPcuH5YC3sHzOdjj4EMT43muheg0B/zFnQIUDkmzlTY97SAmuuUITwCMmrGhd7ze5H0ML3UyuAKlQ+lJCk29AOK6CftepRaAzyl77YClyhz/GGmEDr1F1AAYODahEaWlbwirG0LkqLPNRgB\"}],\"stop_reason\":\"tool_use\",\"stop_sequence\":null,\"stop_details\":null,\"usage\":{\"input_tokens\":124,\"cache_creation_input_tokens\":875,\"cache_read_input_tokens\":46831,\"output_tokens\":257,\"server_tool_use\":{\"web_search_requests\":0,\"web_fetch_requests\":0},\"service_tier\":\"standard\",\"cache_creation\":{\"ephemeral_1h_input_tokens\":875,\"ephemeral_5m_input_tokens\":0},\"inference_geo\":\"not_available\",\"iterations\":[{\"input_tokens\":124,\"output_tokens\":257,\"cache_read_input_tokens\":46831,\"cache_creation_input_tokens\":875,\"cache_creation\":{\"ephemeral_5m_input_tokens\":0,\"ephemeral_1h_input_tokens\":875},\"type\":\"message\"}],\"speed\":\"standard\"},\"diagnostics\":null},\"requestId\":\"req_011Cc7PxuwkWsWPio869WCiK\",\"attributionMcpServer\":\"claude.ai Instafill\",\"attributionMcpTool\":\"get_form_fields\",\"type\":\"assistant\",\"uuid\":\"b19ab892-e531-4f5b-a4dc-5d305aa4ad9c\",\"timestamp\":\"2026-06-16T18:16:47.601Z\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"C:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"parentUuid\":\"b19ab892-e531-4f5b-a4dc-5d305aa4ad9c\",\"isSidechain\":false,\"message\":{\"model\":\"claude-opus-4-8\",\"id\":\"msg_01EvBHUKrMKpe2radzKJQtTd\",\"type\":\"message\",\"role\":\"assistant\",\"content\":[{\"type\":\"text\",\"text\":\"Found it — field `f653` \\\"Insured Phone Number\\\" is currently type **Number**, which is exactly why it was rendered as `5,550,192` (number formatting with thousands separators). I'll switch it to **Text**.\"}],\"stop_reason\":\"tool_use\",\"stop_sequence\":null,\"stop_details\":null,\"usage\":{\"input_tokens\":124,\"cache_creation_input_tokens\":875,\"cache_read_input_tokens\":46831,\"output_tokens\":257,\"server_tool_use\":{\"web_search_requests\":0,\"web_fetch_requests\":0},\"service_tier\":\"standard\",\"cache_creation\":{\"ephemeral_1h_input_tokens\":875,\"ephemeral_5m_input_tokens\":0},\"inference_geo\":\"not_available\",\"iterations\":[{\"input_tokens\":124,\"output_tokens\":257,\"cache_read_input_tokens\":46831,\"cache_creation_input_tokens\":875,\"cache_creation\":{\"ephemeral_5m_input_tokens\":0,\"ephemeral_1h_input_tokens\":875},\"type\":\"message\"}],\"speed\":\"standard\"},\"diagnostics\":null},\"requestId\":\"req_011Cc7PxuwkWsWPio869WCiK\",\"attributionMcpServer\":\"claude.ai Instafill\",\"attributionMcpTool\":\"get_form_fields\",\"type\":\"assistant\",\"uuid\":\"92f1ffbc-371b-404e-9f43-c39540f1b1f6\",\"timestamp\":\"2026-06-16T18:16:49.042Z\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"C:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"parentUuid\":\"92f1ffbc-371b-404e-9f43-c39540f1b1f6\",\"isSidechain\":false,\"message\":{\"model\":\"claude-opus-4-8\",\"id\":\"msg_01EvBHUKrMKpe2radzKJQtTd\",\"type\":\"message\",\"role\":\"assistant\",\"content\":[{\"type\":\"tool_use\",\"id\":\"toolu_01AJuy61WYMEANRv8MEonqz5\",\"name\":\"mcp__claude_ai_Instafill__update_form_fields\",\"input\":{\"formId\":\"6a3185a67577317a2d1300ae\",\"fields\":[{\"field_id\":\"f653\",\"form_type\":\"Text\"}]},\"caller\":{\"type\":\"direct\"}}],\"stop_reason\":\"tool_use\",\"stop_sequence\":null,\"stop_details\":null,\"usage\":{\"input_tokens\":124,\"cache_creation_input_tokens\":875,\"cache_read_input_tokens\":46831,\"output_tokens\":257,\"server_tool_use\":{\"web_search_requests\":0,\"web_fetch_requests\":0},\"service_tier\":\"standard\",\"cache_creation\":{\"ephemeral_1h_input_tokens\":875,\"ephemeral_5m_input_tokens\":0},\"inference_geo\":\"not_available\",\"iterations\":[{\"input_tokens\":124,\"output_tokens\":257,\"cache_read_input_tokens\":46831,\"cache_creation_input_tokens\":875,\"cache_creation\":{\"ephemeral_5m_input_tokens\":0,\"ephemeral_1h_input_tokens\":875},\"type\":\"message\"}],\"speed\":\"standard\"},\"diagnostics\":null},\"requestId\":\"req_011Cc7PxuwkWsWPio869WCiK\",\"attributionMcpServer\":\"claude.ai Instafill\",\"attributionMcpTool\":\"get_form_fields\",\"type\":\"assistant\",\"uuid\":\"6a85d3e3-5b78-4342-99ee-f1407553a2ec\",\"timestamp\":\"2026-06-16T18:16:49.934Z\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"C:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"parentUuid\":\"6a85d3e3-5b78-4342-99ee-f1407553a2ec\",\"isSidechain\":false,\"promptId\":\"6301aad3-e064-44e4-8397-fa03af66d65d\",\"type\":\"user\",\"message\":{\"role\":\"user\",\"content\":[{\"tool_use_id\":\"toolu_01AJuy61WYMEANRv8MEonqz5\",\"type\":\"tool_result\",\"content\":\"{\\\"forms_updated\\\":2,\\\"sessions_updated\\\":2}\"}]},\"uuid\":\"0ca4e3d5-ce74-4599-be9f-180e12f387da\",\"timestamp\":\"2026-06-16T18:16:55.138Z\",\"toolUseResult\":\"{\\\"forms_updated\\\":2,\\\"sessions_updated\\\":2}\",\"mcpMeta\":{\"structuredContent\":{\"forms_updated\":2,\"sessions_updated\":2}},\"sourceToolAssistantUUID\":\"6a85d3e3-5b78-4342-99ee-f1407553a2ec\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"C:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"parentUuid\":\"0ca4e3d5-ce74-4599-be9f-180e12f387da\",\"isSidechain\":false,\"message\":{\"model\":\"claude-opus-4-8\",\"id\":\"msg_01LengBN81nY8Kyd6bBbey3u\",\"type\":\"message\",\"role\":\"assistant\",\"content\":[{\"type\":\"text\",\"text\":\"Done. Changed **Insured Phone Number** (`f653`) from `Number` → `Text`.\\n\\n- The Number type was the cause of the `5,550,192` formatting (thousands separators applied to `5550192`).\\n- `forms_updated: 2, sessions_updated: 2` — the change propagated to your existing fill session, so box 7's telephone should now render as the literal text `+1 (614) 555-0192`.\\n\\nWant me to re-run the fill (or refill just that session) to confirm the phone field now shows 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CHAMPVA.\\\",\\\"group\\\":\\\"Insurance Program Selection\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Group Health Plan\\\",\\\"description\\\":\\\"Check this box if the patient’s coverage for this claim is through a Group Health Plan.\\\",\\\"group\\\":\\\"Insurance Program Selection\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"FECA / Black Lung\\\",\\\"description\\\":\\\"Check this box if the claim is covered under FECA or the Black Lung program.\\\",\\\"group\\\":\\\"Insurance Program Selection\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other\\\",\\\"description\\\":\\\"Check this box if the patient’s coverage for this claim is through another program not listed and enter the program ID number.\\\",\\\"group\\\":\\\"Insurance Program Selection\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured ID Number\\\",\\\"descript\\n...\\n\"}]},\"uuid\":\"6a8ed5e6-973c-475e-ae2c-b5839acc04ba\",\"timestamp\":\"2026-06-16T18:19:14.587Z\",\"toolUseResult\":\"{\\\"session_id\\\":\\\"6a31926c7577317a2d1300be\\\",\\\"form_id\\\":\\\"6a3185a67577317a2d1300ae\\\",\\\"fields\\\":[{\\\"name\\\":\\\"PICA Code (Left)\\\",\\\"description\\\":\\\"Enter the Payer/Carrier Code (PICA) shown on your insurance card or provided by your plan for this claim.\\\",\\\"group\\\":\\\"Payer/Carrier Codes (PICA)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"PICA1 (top left)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"PICA2 (top left)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"PICA3 (top left)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"PICA Code (Right)\\\",\\\"description\\\":\\\"Enter the Payer/Carrier Code (PICA) for the carrier receiving this claim, if a separate PICA code is required.\\\",\\\"group\\\":\\\"Payer/Carrier Codes (PICA)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"PICA1 (top right)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"PICA2 (top right)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"PICA3 (top right)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Medicare\\\",\\\"description\\\":\\\"Check this box if the patient’s coverage for this claim is through Medicare.\\\",\\\"group\\\":\\\"Insurance Program Selection\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Medicaid\\\",\\\"description\\\":\\\"Check this box if the patient’s coverage for this claim is through Medicaid.\\\",\\\"group\\\":\\\"Insurance Program Selection\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"TRICARE\\\",\\\"description\\\":\\\"Check this box if the patient’s coverage for this claim is through TRICARE.\\\",\\\"group\\\":\\\"Insurance Program Selection\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"CHAMPVA\\\",\\\"description\\\":\\\"Check this box if the patient’s coverage for this claim is through CHAMPVA.\\\",\\\"group\\\":\\\"Insurance Program Selection\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Group Health Plan\\\",\\\"description\\\":\\\"Check this box if the patient’s coverage for this claim is through a Group Health Plan.\\\",\\\"group\\\":\\\"Insurance Program Selection\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"FECA / Black Lung\\\",\\\"description\\\":\\\"Check this box if the claim is covered under FECA or the Black Lung program.\\\",\\\"group\\\":\\\"Insurance Program Selection\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other\\\",\\\"description\\\":\\\"Check this box if the patient’s coverage for this claim is through another program not listed and enter the program ID number.\\\",\\\"group\\\":\\\"Insurance Program Selection\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured ID Number\\\",\\\"description\\\":\\\"Enter the insured person’s identification number exactly as shown on the insurance card. Fill only if 'Medicare', 'Medicaid', 'TRICARE', 'CHAMPVA', 'Group Health Plan', 'FECA / Black Lung', 'Other' is 'Yes' (any).\\\",\\\"group\\\":\\\"Patient & Insured Basic Info\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Patient Name\\\",\\\"description\\\":\\\"Enter the patient’s full name (last name, first name, and middle initial).\\\",\\\"group\\\":\\\"Patient & Insured Basic Info\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Patient Birth Month\\\",\\\"description\\\":\\\"Enter the month of the patient’s date of birth.\\\",\\\"group\\\":\\\"Patient & Insured Basic Info\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Patient Birth Day\\\",\\\"description\\\":\\\"Enter the day of the month of the patient’s date of birth.\\\",\\\"group\\\":\\\"Patient & Insured Basic Info\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Patient Birth Year\\\",\\\"description\\\":\\\"Enter the year of the patient’s date of birth.\\\",\\\"group\\\":\\\"Patient & Insured Basic Info\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Sex: Male\\\",\\\"description\\\":\\\"Check this box if the patient is male.\\\",\\\"group\\\":\\\"Patient & Insured Basic Info\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Sex: Female\\\",\\\"description\\\":\\\"Check this box if the patient is female.\\\",\\\"group\\\":\\\"Patient & Insured Basic Info\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured Name\\\",\\\"description\\\":\\\"Enter the insured person’s full name (last name, first name, and middle initial).\\\",\\\"group\\\":\\\"Patient & Insured Basic Info\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Patient Street Address\\\",\\\"description\\\":\\\"Enter the patient's street address (house/building number and street name).\\\",\\\"group\\\":\\\"Patient Address & Phone\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Patient City\\\",\\\"description\\\":\\\"Enter the city where the patient lives.\\\",\\\"group\\\":\\\"Patient Address & Phone\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Patient State\\\",\\\"description\\\":\\\"Enter the state where the patient lives.\\\",\\\"group\\\":\\\"Patient Address & Phone\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Patient ZIP Code\\\",\\\"description\\\":\\\"Enter the patient's ZIP or postal code.\\\",\\\"group\\\":\\\"Patient Address & Phone\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Patient Telephone (Area Code)\\\",\\\"description\\\":\\\"Enter the area code for the patient's telephone number.\\\",\\\"group\\\":\\\"Patient Address & Phone\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Patient Telephone Number\\\",\\\"description\\\":\\\"Enter the patient's telephone number.\\\",\\\"group\\\":\\\"Patient Address & Phone\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Self\\\",\\\"description\\\":\\\"Check this box if the patient is the insured person (the policyholder).\\\",\\\"group\\\":\\\"Patient Relationship to Insured\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Spouse\\\",\\\"description\\\":\\\"Check this box if the patient is the insured person’s spouse.\\\",\\\"group\\\":\\\"Patient Relationship to Insured\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Child\\\",\\\"description\\\":\\\"Check this box if the patient is the insured person’s child (dependent).\\\",\\\"group\\\":\\\"Patient Relationship to Insured\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other\\\",\\\"description\\\":\\\"Check this box if the patient’s relationship to the insured is not self, spouse, or child.\\\",\\\"group\\\":\\\"Patient Relationship to Insured\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured Street Address\\\",\\\"description\\\":\\\"Enter the insured’s street address (number and street name).\\\",\\\"group\\\":\\\"Insured Address & Phone\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured City\\\",\\\"description\\\":\\\"Enter the city for the insured’s mailing address.\\\",\\\"group\\\":\\\"Insured Address & Phone\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured State\\\",\\\"description\\\":\\\"Enter the state for the insured’s mailing address.\\\",\\\"group\\\":\\\"Insured Address & Phone\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured ZIP Code\\\",\\\"description\\\":\\\"Enter the ZIP code for the insured’s mailing address.\\\",\\\"group\\\":\\\"Insured Address & Phone\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured Phone Area Code\\\",\\\"description\\\":\\\"Enter the area code for the insured’s telephone number.\\\",\\\"group\\\":\\\"Insured Address & Phone\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured Phone Number\\\",\\\"description\\\":\\\"Enter the insured’s telephone number excluding the area code.\\\",\\\"group\\\":\\\"Insured Address & Phone\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"NUCC Use (Item 8)\\\",\\\"description\\\":\\\"Enter any code or information provided by NUCC for Item 8, if applicable; otherwise leave blank.\\\",\\\"group\\\":\\\"Reserved for NUCC Use (Item 8)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other Insured Name\\\",\\\"description\\\":\\\"Enter the other insured person’s full name (last name, first name, middle initial) as it appears on their insurance card. Fill only if 'Yes' is 'Yes'.\\\",\\\"group\\\":\\\"Other Insured Information\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other Insured Policy/Group Number\\\",\\\"description\\\":\\\"Enter the policy number or group number for the other insured person’s health plan. Fill only if 'Yes' is 'Yes'.\\\",\\\"group\\\":\\\"Other Insured Information\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Reserved for NUCC Use (9b)\\\",\\\"description\\\":\\\"Enter the value requested for this reserved NUCC field, if instructed to do so by the payer. Fill only if 'Yes' is 'Yes'.\\\",\\\"group\\\":\\\"Other Insured Information\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Reserved for NUCC Use (9c)\\\",\\\"description\\\":\\\"Enter the value requested for this reserved NUCC field, if instructed to do so by the payer. Fill only if 'Yes' is 'Yes'.\\\",\\\"group\\\":\\\"Other Insured Information\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other Insurance Plan/Program Name\\\",\\\"description\\\":\\\"Enter the name of the other insured person’s insurance plan or program. Fill only if 'Yes' is 'Yes'.\\\",\\\"group\\\":\\\"Other Insured Information\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Employment? (Current or Previous) — Yes\\\",\\\"description\\\":\\\"Check this box if the patient’s condition is related to current or previous employment.\\\",\\\"group\\\":\\\"Patient Condition Related To (Employment/Accidents)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Employment? (Current or Previous) — No\\\",\\\"description\\\":\\\"Check this box if the patient’s condition is not related to current or previous employment.\\\",\\\"group\\\":\\\"Patient Condition Related To (Employment/Accidents)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Auto Accident? — Yes\\\",\\\"description\\\":\\\"Check this box if the patient’s condition is related to an automobile accident.\\\",\\\"group\\\":\\\"Patient Condition Related To (Employment/Accidents)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Auto Accident? — No\\\",\\\"description\\\":\\\"Check this box if the patient’s condition is not related to an automobile accident.\\\",\\\"group\\\":\\\"Patient Condition Related To (Employment/Accidents)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Auto Accident Location (State)\\\",\\\"description\\\":\\\"Enter the U.S. state where the auto accident occurred, if the patient’s condition is related to an auto accident. Fill only if 'Auto Accident? — Yes' is 'Yes'.\\\",\\\"group\\\":\\\"Patient Condition Related To (Employment/Accidents)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other Accident? — Yes\\\",\\\"description\\\":\\\"Check this box if the patient’s condition is related to an accident other than an auto accident.\\\",\\\"group\\\":\\\"Patient Condition Related To (Employment/Accidents)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other Accident? — No\\\",\\\"description\\\":\\\"Check this box if the patient’s condition is not related to any accident other than an auto accident.\\\",\\\"group\\\":\\\"Patient Condition Related To (Employment/Accidents)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Claim Codes (10d)\\\",\\\"description\\\":\\\"Enter any applicable claim codes for this claim as designated by the NUCC.\\\",\\\"group\\\":\\\"Claim Codes (10d)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured Policy Group or FECA Number\\\",\\\"description\\\":\\\"Enter the insured person’s policy group number or FECA number as shown on the insurance information.\\\",\\\"group\\\":\\\"Insured Policy & Demographics\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured Date of Birth (Month)\\\",\\\"description\\\":\\\"Enter the month of the insured person’s date of birth.\\\",\\\"group\\\":\\\"Insured Policy & Demographics\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured Date of Birth (Day)\\\",\\\"description\\\":\\\"Enter the day of the month of the insured person’s date of birth.\\\",\\\"group\\\":\\\"Insured Policy & Demographics\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured Date of Birth (Year)\\\",\\\"description\\\":\\\"Enter the year of the insured person’s date of birth.\\\",\\\"group\\\":\\\"Insured Policy & Demographics\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Sex - Male (M)\\\",\\\"description\\\":\\\"Check this box if the insured person is male.\\\",\\\"group\\\":\\\"Insured Policy & Demographics\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Sex - Female (F)\\\",\\\"description\\\":\\\"Check this box if the insured person is female.\\\",\\\"group\\\":\\\"Insured Policy & Demographics\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other Claim ID Qualifier\\\",\\\"description\\\":\\\"Enter the qualifier code that identifies the type/source of the other claim ID.\\\",\\\"group\\\":\\\"Other Claim ID & Plan Name\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other Claim ID\\\",\\\"description\\\":\\\"Enter the other claim identification number associated with the patient’s coverage.\\\",\\\"group\\\":\\\"Other Claim ID & Plan Name\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other Insurance Plan Name\\\",\\\"description\\\":\\\"Enter the name of the other insurance plan or program related to the other claim.\\\",\\\"group\\\":\\\"Other Claim ID & Plan Name\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Yes\\\",\\\"description\\\":\\\"Check this box if the patient is covered by another health benefit plan in addition to the plan listed on this claim.\\\",\\\"group\\\":\\\"Another Health Benefit Plan (11d)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"No\\\",\\\"description\\\":\\\"Check this box if the patient is not covered by any other health benefit plan besides the plan listed on this claim.\\\",\\\"group\\\":\\\"Another Health Benefit Plan (11d)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Patient/Authorized Person Signature\\\",\\\"description\\\":\\\"Enter the signature of the patient or the authorized person who is signing to authorize release of information and payment of benefits.\\\",\\\"group\\\":\\\"Patient/Insured Signatures & Dates\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Signature Date (Patient/Authorized Person)\\\",\\\"description\\\":\\\"Enter the date the patient or authorized person signed the form.\\\",\\\"group\\\":\\\"Patient/Insured Signatures & Dates\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured/Authorized Person Signature\\\",\\\"description\\\":\\\"Enter the signature of the insured or authorized person authorizing payment of medical benefits to the provider or supplier.\\\",\\\"group\\\":\\\"Patient/Insured Signatures & Dates\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Current Illness/Injury Date - Month\\\",\\\"description\\\":\\\"Enter the month of the date of current illness, injury, or pregnancy (LMP).\\\",\\\"group\\\":\\\"Illness/Injury/Other Dates (Items 14-15)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Current Illness/Injury Date - Day\\\",\\\"description\\\":\\\"Enter the day of the date of current illness, injury, or pregnancy (LMP).\\\",\\\"group\\\":\\\"Illness/Injury/Other Dates (Items 14-15)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Current Illness/Injury Date - Year\\\",\\\"description\\\":\\\"Enter the year of the date of current illness, injury, or pregnancy (LMP).\\\",\\\"group\\\":\\\"Illness/Injury/Other Dates (Items 14-15)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Current Illness/Injury Date Qualifier\\\",\\\"description\\\":\\\"Enter the qualifier code that indicates what the date of current illness, injury, or pregnancy represents.\\\",\\\"group\\\":\\\"Illness/Injury/Other Dates (Items 14-15)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other Date Qualifier\\\",\\\"description\\\":\\\"Enter the qualifier code that indicates what the other date represents.\\\",\\\"group\\\":\\\"Illness/Injury/Other Dates (Items 14-15)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other Date - Month\\\",\\\"description\\\":\\\"Enter the month for the other date indicated by the qualifier.\\\",\\\"group\\\":\\\"Illness/Injury/Other Dates (Items 14-15)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other Date - Day\\\",\\\"description\\\":\\\"Enter the day for the other date indicated by the qualifier.\\\",\\\"group\\\":\\\"Illness/Injury/Other Dates (Items 14-15)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other Date - Year\\\",\\\"description\\\":\\\"Enter the year for the other date indicated by the qualifier.\\\",\\\"group\\\":\\\"Illness/Injury/Other Dates (Items 14-15)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Unable to Work From (Month)\\\",\\\"description\\\":\\\"Enter the month when the patient first became unable to work in their current occupation.\\\",\\\"group\\\":\\\"Unable to Work Dates (Item 16)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Unable to Work From (Day)\\\",\\\"description\\\":\\\"Enter the day of the month when the patient first became unable to work in their current occupation.\\\",\\\"group\\\":\\\"Unable to Work Dates (Item 16)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Unable to Work From (Year)\\\",\\\"description\\\":\\\"Enter the year when the patient first became unable to work in their current occupation.\\\",\\\"group\\\":\\\"Unable to Work Dates (Item 16)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Unable to Work To (Month)\\\",\\\"description\\\":\\\"Enter the month when the patient returned to work (or the end month of the period they were unable to work).\\\",\\\"group\\\":\\\"Unable to Work Dates (Item 16)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Unable to Work To (Day)\\\",\\\"description\\\":\\\"Enter the day of the month when the patient returned to work (or the end day of the period they were unable to work).\\\",\\\"group\\\":\\\"Unable to Work Dates (Item 16)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Unable to Work To (Year)\\\",\\\"description\\\":\\\"Enter the year when the patient returned to work (or the end year of the period they were unable to work).\\\",\\\"group\\\":\\\"Unable to Work Dates (Item 16)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Referring provider last name\\\",\\\"description\\\":\\\"Enter the referring provider’s last name.\\\",\\\"group\\\":\\\"Referring Provider Information (Item 17)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Referring provider first name\\\",\\\"description\\\":\\\"Enter the referring provider’s first name (and middle initial if applicable).\\\",\\\"group\\\":\\\"Referring Provider Information (Item 17)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Referring provider ID qualifier (17a)\\\",\\\"description\\\":\\\"Enter the qualifier that identifies the type of non-NPI referring provider ID reported in Item 17a.\\\",\\\"group\\\":\\\"Referring Provider Information (Item 17)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Referring provider ID number (17a)\\\",\\\"description\\\":\\\"Enter the referring provider’s non-NPI identification number corresponding to the qualifier in Item 17a.\\\",\\\"group\\\":\\\"Referring Provider Information (Item 17)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Referring provider NPI (17b)\\\",\\\"description\\\":\\\"Enter the referring provider’s National Provider Identifier (NPI).\\\",\\\"group\\\":\\\"Referring Provider Information (Item 17)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Hospitalization From - Month\\\",\\\"description\\\":\\\"Enter the month the hospitalization began (FROM date).\\\",\\\"group\\\":\\\"Hospitalization Dates (Item 18)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Hospitalization From - Day\\\",\\\"description\\\":\\\"Enter the day of the month the hospitalization began (FROM date).\\\",\\\"group\\\":\\\"Hospitalization Dates (Item 18)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Hospitalization From - Year\\\",\\\"description\\\":\\\"Enter the year the hospitalization began (FROM date).\\\",\\\"group\\\":\\\"Hospitalization Dates (Item 18)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Hospitalization To - Month\\\",\\\"description\\\":\\\"Enter the month the hospitalization ended (TO date). Fill only if 'Hospitalization From - Day' is 'Yes'.\\\",\\\"group\\\":\\\"Hospitalization Dates (Item 18)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Hospitalization To - Day\\\",\\\"description\\\":\\\"Enter the day of the month the hospitalization ended (TO date).\\\",\\\"group\\\":\\\"Hospitalization Dates (Item 18)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Hospitalization To - Year\\\",\\\"description\\\":\\\"Enter the year the hospitalization ended (TO date).\\\",\\\"group\\\":\\\"Hospitalization Dates (Item 18)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Additional Claim Information\\\",\\\"description\\\":\\\"Enter any additional claim information or remarks designated by NUCC that apply to this claim.\\\",\\\"group\\\":\\\"Additional Claim Info & Outside Lab (Items 19-20)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Outside Lab: Yes\\\",\\\"description\\\":\\\"Check this box if the lab work for this claim was performed by an outside (non-office) laboratory.\\\",\\\"group\\\":\\\"Additional Claim Info & Outside Lab (Items 19-20)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Outside Lab: No\\\",\\\"description\\\":\\\"Check this box if the lab work for this claim was not performed by an outside laboratory.\\\",\\\"group\\\":\\\"Additional Claim Info & Outside Lab (Items 19-20)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Outside Lab Indicator\\\",\\\"description\\\":\\\"Indicate whether the services were performed by an outside laboratory (e.g., enter Yes or No).\\\",\\\"group\\\":\\\"Additional Claim Info & Outside Lab (Items 19-20)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Outside Lab Charges\\\",\\\"description\\\":\\\"Enter the total charges amount for services performed by an outside laboratory.\\\",\\\"group\\\":\\\"Additional Claim Info & Outside Lab (Items 19-20)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"ICD Indicator\\\",\\\"description\\\":\\\"Enter the ICD code set indicator that applies to the diagnosis codes listed (as required by the form).\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Code A\\\",\\\"description\\\":\\\"Enter the primary diagnosis code (A) describing the patient’s illness or injury.\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Code B\\\",\\\"description\\\":\\\"Enter diagnosis code B describing the patient’s illness or injury.\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Code C\\\",\\\"description\\\":\\\"Enter diagnosis code C describing the patient’s illness or injury.\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Code D\\\",\\\"description\\\":\\\"Enter diagnosis code D describing the patient’s illness or injury.\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Code E\\\",\\\"description\\\":\\\"Enter diagnosis code E describing the patient’s illness or injury.\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Code F\\\",\\\"description\\\":\\\"Enter diagnosis code F describing the patient’s illness or injury.\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Code G\\\",\\\"description\\\":\\\"Enter diagnosis code G describing the patient’s illness or injury.\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Code H\\\",\\\"description\\\":\\\"Enter diagnosis code H describing the patient’s illness or injury.\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Code I\\\",\\\"description\\\":\\\"Enter diagnosis code I describing the patient’s illness or injury.\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Code J\\\",\\\"description\\\":\\\"Enter diagnosis code J describing the patient’s illness or injury.\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Code K\\\",\\\"description\\\":\\\"Enter diagnosis code K describing the patient’s illness or injury.\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Code L\\\",\\\"description\\\":\\\"Enter diagnosis code L describing the patient’s illness or injury.\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Code M\\\",\\\"description\\\":\\\"Enter an additional diagnosis code (M) describing the patient’s illness or injury, if applicable.\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Resubmission Code\\\",\\\"description\\\":\\\"Enter the code that indicates this claim is a resubmission or corrected/replacement claim, if applicable.\\\",\\\"group\\\":\\\"Resubmission & Original Reference (Item 22)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Original Reference Number\\\",\\\"description\\\":\\\"Enter the reference number or identifier for the original claim being resubmitted or corrected.\\\",\\\"group\\\":\\\"Resubmission & Original Reference (Item 22)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Prior Authorization Number\\\",\\\"description\\\":\\\"Enter the prior authorization number issued for the services being claimed (Item 23).\\\",\\\"group\\\":\\\"Prior Authorization Number (Item 23)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service From Month\\\",\\\"description\\\":\\\"Enter the month of the start date of service for this service line.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service From Day\\\",\\\"description\\\":\\\"Enter the day of the start date of service for this service line.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service From Year\\\",\\\"description\\\":\\\"Enter the year of the start date of service for this service line.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service To Month\\\",\\\"description\\\":\\\"Enter the month of the end date of service for this service line, if applicable.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service To Day\\\",\\\"description\\\":\\\"Enter the day of the end date of service for this service line, if applicable.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service To Year\\\",\\\"description\\\":\\\"Enter the year of the end date of service for this service line, if applicable.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Place of Service\\\",\\\"description\\\":\\\"Enter the place of service code that indicates where the service was provided.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Emergency Indicator\\\",\\\"description\\\":\\\"Enter the emergency indicator value for this service line, if required.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Procedure Code (CPT/HCPCS)\\\",\\\"description\\\":\\\"Enter the CPT or HCPCS procedure code for the service provided.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Modifier 1\\\",\\\"description\\\":\\\"Enter the first procedure modifier, if applicable.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Modifier 2\\\",\\\"description\\\":\\\"Enter the second procedure modifier, if applicable.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Modifier 3\\\",\\\"description\\\":\\\"Enter the third procedure modifier, if applicable.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Modifier 4\\\",\\\"description\\\":\\\"Enter the fourth procedure modifier, if applicable.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Pointer\\\",\\\"description\\\":\\\"Enter the diagnosis code reference(s) (pointer) that apply to this procedure.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Line Item Charges\\\",\\\"description\\\":\\\"Enter the total charge amount for this service line.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Days or Units\\\",\\\"description\\\":\\\"Enter the number of days or units billed for this service line.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"EPSDT/Family Plan\\\",\\\"description\\\":\\\"Enter the EPSDT or family planning indicator/code, if applicable.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Rendering Provider ID Qualifier\\\",\\\"description\\\":\\\"Enter the qualifier that identifies the type of non-NPI rendering provider identifier being reported.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Rendering Provider NPI\\\",\\\"description\\\":\\\"Enter the rendering provider’s National Provider Identifier (NPI) for this service line.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Row 1 — 24J Rendering Provider ID #\\\",\\\"description\\\":\\\"Enter the rendering provider's identifier for Row 1 (24J), for example the provider's NPI or other assigned ID.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Rendering Provider Other ID\\\",\\\"description\\\":\\\"Enter the rendering provider’s non-NPI identifier for this service line, if applicable.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Date From (Month)\\\",\\\"description\\\":\\\"Enter the month portion of the beginning date of service for the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Date From (Day)\\\",\\\"description\\\":\\\"Enter the day portion of the beginning date of service for the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Date From (Year)\\\",\\\"description\\\":\\\"Enter the year portion of the beginning date of service for the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Date To (Month)\\\",\\\"description\\\":\\\"Enter the month portion of the ending date of service for the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Date To (Day)\\\",\\\"description\\\":\\\"Enter the day portion of the ending date of service for the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Date To (Year)\\\",\\\"description\\\":\\\"Enter the year portion of the ending date of service for the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Place of Service Code\\\",\\\"description\\\":\\\"Enter the place of service code that identifies where the services were provided for the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Emergency Indicator (EMG)\\\",\\\"description\\\":\\\"Enter the emergency indicator value for the second service line, if applicable.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Procedure Code (CPT/HCPCS)\\\",\\\"description\\\":\\\"Enter the CPT or HCPCS procedure/service code for the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Procedure Modifier 1\\\",\\\"description\\\":\\\"Enter the first procedure modifier associated with the procedure code for the second service line, if any.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Procedure Modifier 2\\\",\\\"description\\\":\\\"Enter the second procedure modifier associated with the procedure code for the second service line, if any.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Procedure Modifier 3\\\",\\\"description\\\":\\\"Enter the third procedure modifier associated with the procedure code for the second service line, if any.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Procedure Modifier 4\\\",\\\"description\\\":\\\"Enter the fourth procedure modifier associated with the procedure code for the second service line, if any.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Pointer\\\",\\\"description\\\":\\\"Enter the diagnosis pointer(s) that link this service to the relevant diagnosis code(s) for the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Line Item Charge Amount\\\",\\\"description\\\":\\\"Enter the total charge amount being billed for the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Days or Units\\\",\\\"description\\\":\\\"Enter the number of days or units for the billed service on the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"EPSDT Indicator\\\",\\\"description\\\":\\\"Enter the EPSDT indicator value for the second service line, if applicable.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Family Planning Indicator\\\",\\\"description\\\":\\\"Enter the family planning indicator value for the second service line, if applicable.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Rendering Provider ID Qualifier\\\",\\\"description\\\":\\\"Enter the qualifier that identifies the type of rendering provider identifier reported for the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Rendering Provider NPI\\\",\\\"description\\\":\\\"Enter the rendering provider's NPI for the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Rendering Provider Other ID\\\",\\\"description\\\":\\\"Enter the rendering provider's other identifier (non-NPI), if applicable, for the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"From Date of Service - Month\\\",\\\"description\\\":\\\"Enter the month of the start (FROM) date of service for this third service line.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"From Date of Service - Day\\\",\\\"description\\\":\\\"Enter the day of the start (FROM) date of service for this third service line.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"From Date of Service - Year\\\",\\\"description\\\":\\\"Enter the year of the start (FROM) date of service for this third service line.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"To Date of Service - Month\\\",\\\"description\\\":\\\"Enter the month of the end (TO) date of service for this third service line, if different from the from date.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"To Date of Service - Day\\\",\\\"description\\\":\\\"Enter the day of the end (TO) date of service for this third service line, if different from the from date.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"To Date of Service - Year\\\",\\\"description\\\":\\\"Enter the year of the end (TO) date of service for this third service line, if different from the from date.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Place of Service\\\",\\\"description\\\":\\\"Enter the place of service code for where the service was performed on this third service line.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Emergency Indicator\\\",\\\"description\\\":\\\"Enter the emergency indicator for this third service line, if applicable.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Procedure/Service Code (CPT/HCPCS)\\\",\\\"description\\\":\\\"Enter the CPT/HCPCS procedure or service code billed on this third service line.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Modifier 1\\\",\\\"description\\\":\\\"Enter the first procedure modifier for the CPT/HCPCS code on this third service line, if applicable.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Modifier 2\\\",\\\"description\\\":\\\"Enter the second procedure modifier for the CPT/HCPCS code on this third service line, if applicable.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Modifier 3\\\",\\\"description\\\":\\\"Enter the third procedure modifier for the CPT/HCPCS code on this third service line, if applicable.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Modifier 4\\\",\\\"description\\\":\\\"Enter the fourth procedure modifier for the CPT/HCPCS code on this third service line, if applicable.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Pointer\\\",\\\"description\\\":\\\"Enter the diagnosis code reference letter(s) (from Item 21) that apply to this third service line.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Charges - Dollars\\\",\\\"description\\\":\\\"Enter the dollar amount charged for this third service line.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Charges - Cents\\\",\\\"description\\\":\\\"Enter the cents portion of the amount charged for this third service line.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Days or Units\\\",\\\"description\\\":\\\"Enter the number of days or units for the service billed on this third service line.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"EPSDT/Family Plan\\\",\\\"description\\\":\\\"Enter the EPSDT/Family Plan indicator for this third service line, if applicable.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Rendering Provider ID Qualifier\\\",\\\"description\\\":\\\"Enter the qualifier that identifies the type of non-NPI rendering provider identifier reported for this third service line, if applicable.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Rendering Provider NPI\\\",\\\"description\\\":\\\"Enter the rendering provider's NPI for this third service line.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Rendering Provider Other ID\\\",\\\"description\\\":\\\"Enter the rendering provider's non-NPI identifier for this third service line, if applicable.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 From Date (MM)\\\",\\\"description\\\":\\\"Enter the month of the start date for the service period on this service line.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 From Date (DD)\\\",\\\"description\\\":\\\"Enter the day of the start date for the service period on this service line.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 From Date (YY)\\\",\\\"description\\\":\\\"Enter the two-digit year of the start date for the service period on this service line.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 To Date (MM)\\\",\\\"description\\\":\\\"Enter the month of the end date for the service period on this service line.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 To Date (DD)\\\",\\\"description\\\":\\\"Enter the day of the end date for the service period on this service line.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 To Date (YY)\\\",\\\"description\\\":\\\"Enter the two-digit year of the end date for the service period on this service line.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Place of Service\\\",\\\"description\\\":\\\"Enter the place of service code that describes where the service was provided for this service line.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Emergency Indicator\\\",\\\"description\\\":\\\"Enter the emergency indicator value for this service line, if applicable.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Procedure Code (CPT/HCPCS)\\\",\\\"description\\\":\\\"Enter the CPT/HCPCS procedure code for the service or item billed on this service line.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Modifier 1\\\",\\\"description\\\":\\\"Enter the first procedure modifier associated with the billed procedure code on this service line, if any.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Modifier 2\\\",\\\"description\\\":\\\"Enter the second procedure modifier associated with the billed procedure code on this service line, if any.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Modifier 3\\\",\\\"description\\\":\\\"Enter the third procedure modifier associated with the billed procedure code on this service line, if any.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Modifier 4\\\",\\\"description\\\":\\\"Enter the fourth procedure modifier associated with the billed procedure code on this service line, if any.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Diagnosis Pointer\\\",\\\"description\\\":\\\"Enter the diagnosis pointer(s) that link this service line to the diagnosis code(s) listed in the diagnosis section.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Charges\\\",\\\"description\\\":\\\"Enter the total charge amount being billed for this service line.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Days or Units\\\",\\\"description\\\":\\\"Enter the number of days or units for the service billed on this service line.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 EPSDT/Family Plan\\\",\\\"description\\\":\\\"Enter the EPSDT or family planning indicator for this service line, if applicable.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Provider ID Qualifier\\\",\\\"description\\\":\\\"Enter the qualifier that identifies the type of provider ID reported for this service line, if applicable.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Rendering Provider ID (Non-NPI)\\\",\\\"description\\\":\\\"Enter the rendering provider's non-NPI identifier for this service line, if required by the payer.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Rendering Provider NPI\\\",\\\"description\\\":\\\"Enter the rendering provider's National Provider Identifier (NPI) for this service line.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Rendering Provider NPI (Alternate Box)\\\",\\\"description\\\":\\\"Enter the rendering provider's National Provider Identifier (NPI) for this service line if the form uses this second identifier box.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"From Date of Service - Month\\\",\\\"description\\\":\\\"Enter the month portion of the start date for this fifth service line.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"From Date of Service - Day\\\",\\\"description\\\":\\\"Enter the day portion of the start date for this fifth service line.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"From Date of Service - Year\\\",\\\"description\\\":\\\"Enter the year portion of the start date for this fifth service line.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"To Date of Service - Month\\\",\\\"description\\\":\\\"Enter the month portion of the end date for this fifth service line (if different from the from date).\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"To Date of Service - Day\\\",\\\"description\\\":\\\"Enter the day portion of the end date for this fifth service line (if different from the from date).\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"To Date of Service - Year\\\",\\\"description\\\":\\\"Enter the year portion of the end date for this fifth service line (if different from the from date).\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Place of Service\\\",\\\"description\\\":\\\"Enter the place of service code for where the service was provided on this fifth service line.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Emergency Indicator (EMG)\\\",\\\"description\\\":\\\"Enter the emergency indicator value for this fifth service line, if applicable.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Procedure/Service Code (CPT/HCPCS)\\\",\\\"description\\\":\\\"Enter the CPT/HCPCS procedure or service code for this fifth service line.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Modifier 1\\\",\\\"description\\\":\\\"Enter the first procedure modifier associated with the CPT/HCPCS code on this fifth service line, if any.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Modifier 2\\\",\\\"description\\\":\\\"Enter the second procedure modifier associated with the CPT/HCPCS code on this fifth service line, if any.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Modifier 3\\\",\\\"description\\\":\\\"Enter the third procedure modifier associated with the CPT/HCPCS code on this fifth service line, if any.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Modifier 4\\\",\\\"description\\\":\\\"Enter the fourth procedure modifier associated with the CPT/HCPCS code on this fifth service line, if any.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Pointer\\\",\\\"description\\\":\\\"Enter the diagnosis pointer(s) (letters/numbers that reference the diagnoses listed in Item 21) that apply to this fifth service line.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Line Item Charges\\\",\\\"description\\\":\\\"Enter the charge amount billed for this fifth service line.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Days or Units\\\",\\\"description\\\":\\\"Enter the number of days or units for the service billed on this fifth service line.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"EPSDT Indicator\\\",\\\"description\\\":\\\"Enter the EPSDT indicator value for this fifth service line, if applicable.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Family Plan Indicator\\\",\\\"description\\\":\\\"Enter the family plan indicator value for this fifth service line, if applicable.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Rendering Provider ID Qualifier\\\",\\\"description\\\":\\\"Enter the qualifier that identifies the type of rendering provider ID reported for this fifth service line.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Rendering Provider ID (Non-NPI)\\\",\\\"description\\\":\\\"Enter the rendering provider's non-NPI identifier for this fifth service line, if required.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Rendering Provider NPI\\\",\\\"description\\\":\\\"Enter the rendering provider's National Provider Identifier (NPI) for this fifth service line.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 From Date (Month)\\\",\\\"description\\\":\\\"Enter the month of the beginning date of service for the sixth service line.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 From Date (Day)\\\",\\\"description\\\":\\\"Enter the day of the beginning date of service for the sixth service line.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 From Date (Year)\\\",\\\"description\\\":\\\"Enter the year of the beginning date of service for the sixth service line.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 To Date (Month)\\\",\\\"description\\\":\\\"Enter the month of the ending date of service for the sixth service line.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 To Date (Day)\\\",\\\"description\\\":\\\"Enter the day of the ending date of service for the sixth service line.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 To Date (Year)\\\",\\\"description\\\":\\\"Enter the year of the ending date of service for the sixth service line.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 Place of Service Code\\\",\\\"description\\\":\\\"Enter the place of service code that identifies where the service was provided for the sixth service line.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 EMG Indicator\\\",\\\"description\\\":\\\"Enter the emergency indicator value for the sixth service line, if applicable.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 CPT/HCPCS Code\\\",\\\"description\\\":\\\"Enter the CPT or HCPCS procedure code for the service billed on the sixth service line.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 Modifier 1\\\",\\\"description\\\":\\\"Enter the first procedure modifier that applies to the CPT/HCPCS code on the sixth service line, if any.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 Modifier 2\\\",\\\"description\\\":\\\"Enter the second procedure modifier that applies to the CPT/HCPCS code on the sixth service line, if any.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 Modifier 3\\\",\\\"description\\\":\\\"Enter the third procedure modifier that applies to the CPT/HCPCS code on the sixth service line, if any.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 Modifier 4\\\",\\\"description\\\":\\\"Enter the fourth procedure modifier that applies to the CPT/HCPCS code on the sixth service line, if any.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 Diagnosis Pointer\\\",\\\"description\\\":\\\"Enter the diagnosis reference letter(s)/number(s) that link this service to the diagnoses listed in Item 21.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 Charge Amount\\\",\\\"description\\\":\\\"Enter the total charge amount being billed for the sixth service line.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 Days or Units\\\",\\\"description\\\":\\\"Enter the number of days or units for the service billed on the sixth service line.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 EPSDT Indicator\\\",\\\"description\\\":\\\"Enter the EPSDT indicator value for the sixth service line, if applicable.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 Family Plan Indicator\\\",\\\"description\\\":\\\"Enter the family plan indicator value for the sixth service line, if applicable.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 Rendering Provider ID Qualifier\\\",\\\"description\\\":\\\"Enter the qualifier that identifies the type of non-NPI rendering provider identifier reported for the sixth service line, if applicable.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 Rendering Provider Other ID\\\",\\\"description\\\":\\\"Enter the rendering provider’s non-NPI identifier for the sixth service line, if applicable.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 Rendering Provider NPI\\\",\\\"description\\\":\\\"Enter the rendering provider’s NPI for the sixth service line.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Federal Tax ID Number\\\",\\\"description\\\":\\\"Enter the billing provider’s Federal Tax Identification Number (TIN).\\\",\\\"group\\\":\\\"Tax ID, Patient Account & Claim Totals (Items 25-30)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Federal Tax ID Type: SSN\\\",\\\"description\\\":\\\"Check this box if the Federal Tax ID number entered in Item 25 is a Social Security Number (SSN).\\\",\\\"group\\\":\\\"Tax ID, Patient Account & Claim Totals (Items 25-30)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Federal Tax ID Type: EIN\\\",\\\"description\\\":\\\"Check this box if the Federal Tax ID number entered in Item 25 is an Employer Identification Number (EIN).\\\",\\\"group\\\":\\\"Tax ID, Patient Account & Claim Totals (Items 25-30)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Patient Account Number\\\",\\\"description\\\":\\\"Enter the patient’s account number used by the provider or facility to identify this claim.\\\",\\\"group\\\":\\\"Tax ID, Patient Account & Claim Totals (Items 25-30)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Accept Assignment: Yes\\\",\\\"description\\\":\\\"Check this box if the provider accepts assignment of benefits for this claim.\\\",\\\"group\\\":\\\"Tax ID, Patient Account & Claim Totals (Items 25-30)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Accept Assignment: No\\\",\\\"description\\\":\\\"Check this box if the provider does not accept assignment of benefits for this claim.\\\",\\\"group\\\":\\\"Tax ID, Patient Account & Claim Totals (Items 25-30)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Total Charge\\\",\\\"description\\\":\\\"Enter the total charges for all services reported on this claim.\\\",\\\"group\\\":\\\"Tax ID, Patient Account & Claim Totals (Items 25-30)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Amount Paid\\\",\\\"description\\\":\\\"Enter the amount already paid toward this claim by the patient and/or other sources.\\\",\\\"group\\\":\\\"Tax ID, Patient Account & Claim Totals (Items 25-30)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Reserved for NUCC Use (Part 1)\\\",\\\"description\\\":\\\"Enter any information required by NUCC or the payer for the first reserved segment of Item 30.\\\",\\\"group\\\":\\\"Tax ID, Patient Account & Claim Totals (Items 25-30)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Reserved for NUCC Use (Part 2)\\\",\\\"description\\\":\\\"Enter any information required by NUCC or the payer for the second reserved segment of Item 30.\\\",\\\"group\\\":\\\"Tax ID, Patient Account & Claim Totals (Items 25-30)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Reserved for NUCC Use (Part 3)\\\",\\\"description\\\":\\\"Enter any information required by NUCC or the payer for the third reserved segment of Item 30.\\\",\\\"group\\\":\\\"Tax ID, Patient Account & Claim Totals (Items 25-30)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Reserved for NUCC Use (Part 4)\\\",\\\"description\\\":\\\"Enter any information required by NUCC or the payer for the fourth reserved segment of Item 30.\\\",\\\"group\\\":\\\"Tax ID, Patient Account & Claim Totals (Items 25-30)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Physician/Supplier Signature\\\",\\\"description\\\":\\\"Enter the signature of the physician or supplier (including degrees or credentials) certifying the claim.\\\",\\\"group\\\":\\\"Physician/Supplier Signature (Item 31)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Signature Date\\\",\\\"description\\\":\\\"Enter the date the physician or supplier signed the claim.\\\",\\\"group\\\":\\\"Physician/Supplier Signature (Item 31)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Facility Name and Address\\\",\\\"description\\\":\\\"Enter the name and full address of the facility where the services were provided (street, city, state, and ZIP code).\\\",\\\"group\\\":\\\"Service Facility Location (Item 32)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Facility NPI\\\",\\\"description\\\":\\\"Enter the National Provider Identifier (NPI) for the service facility.\\\",\\\"group\\\":\\\"Service Facility Location (Item 32)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Facility Other ID\\\",\\\"description\\\":\\\"Enter any additional identification number for the service facility (if applicable).\\\",\\\"group\\\":\\\"Service Facility Location (Item 32)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Billing Provider Phone Area Code\\\",\\\"description\\\":\\\"Enter the area code portion of the billing provider’s phone number.\\\",\\\"group\\\":\\\"Billing Provider Info & Phone (Item 33)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Billing Provider Phone Number\\\",\\\"description\\\":\\\"Enter the remaining digits of the billing provider’s phone number.\\\",\\\"group\\\":\\\"Billing Provider Info & Phone (Item 33)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Billing Provider Name and Address\\\",\\\"description\\\":\\\"Enter the billing provider’s name and mailing address (and other identifying details as needed) as shown in Item 33.\\\",\\\"group\\\":\\\"Billing Provider Info & Phone (Item 33)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Billing Provider NPI (33a)\\\",\\\"description\\\":\\\"Enter the billing provider’s National Provider Identifier (NPI).\\\",\\\"group\\\":\\\"Billing Provider Info & Phone (Item 33)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Billing Provider Other ID (33b)\\\",\\\"description\\\":\\\"Enter the billing provider’s other identifier (if applicable) as required by the payer.\\\",\\\"group\\\":\\\"Billing Provider Info & Phone (Item 33)\\\",\\\"page_num\\\":0}]}\",\"mcpMeta\":{\"structuredContent\":{\"session_id\":\"6a31926c7577317a2d1300be\",\"form_id\":\"6a3185a67577317a2d1300ae\",\"fields\":[{\"name\":\"PICA Code (Left)\",\"description\":\"Enter the Payer/Carrier Code (PICA) shown on your insurance card or provided by your plan for this claim.\",\"group\":\"Payer/Carrier Codes (PICA)\",\"page_num\":0},{\"name\":\"PICA1 (top left)\",\"page_num\":0},{\"name\":\"PICA2 (top left)\",\"page_num\":0},{\"name\":\"PICA3 (top left)\",\"page_num\":0},{\"name\":\"PICA Code (Right)\",\"description\":\"Enter the Payer/Carrier Code (PICA) for the carrier receiving this claim, if a separate PICA code is required.\",\"group\":\"Payer/Carrier Codes (PICA)\",\"page_num\":0},{\"name\":\"PICA1 (top right)\",\"page_num\":0},{\"name\":\"PICA2 (top right)\",\"page_num\":0},{\"name\":\"PICA3 (top right)\",\"page_num\":0},{\"name\":\"Medicare\",\"description\":\"Check this box if the patient’s coverage for this claim is through Medicare.\",\"group\":\"Insurance Program Selection\",\"page_num\":0},{\"name\":\"Medicaid\",\"description\":\"Check this box if the patient’s coverage for this claim is through Medicaid.\",\"group\":\"Insurance Program Selection\",\"page_num\":0},{\"name\":\"TRICARE\",\"description\":\"Check this box if the patient’s coverage for this claim is through TRICARE.\",\"group\":\"Insurance Program Selection\",\"page_num\":0},{\"name\":\"CHAMPVA\",\"description\":\"Check this box if the patient’s coverage for this claim is through CHAMPVA.\",\"group\":\"Insurance Program Selection\",\"page_num\":0},{\"name\":\"Group Health Plan\",\"description\":\"Check this box if the patient’s coverage for this claim is through a Group Health Plan.\",\"group\":\"Insurance Program Selection\",\"page_num\":0},{\"name\":\"FECA / Black Lung\",\"description\":\"Check this box if the claim is covered under FECA or the Black Lung program.\",\"group\":\"Insurance Program Selection\",\"page_num\":0},{\"name\":\"Other\",\"description\":\"Check this box if the patient’s coverage for this claim is through another program not listed and enter the program ID number.\",\"group\":\"Insurance Program Selection\",\"page_num\":0},{\"name\":\"Insured ID Number\",\"description\":\"Enter the insured person’s identification number exactly as shown on the insurance card. Fill only if 'Medicare', 'Medicaid', 'TRICARE', 'CHAMPVA', 'Group Health Plan', 'FECA / Black Lung', 'Other' is 'Yes' (any).\",\"group\":\"Patient & Insured Basic Info\",\"page_num\":0},{\"name\":\"Patient Name\",\"description\":\"Enter the patient’s full name (last name, first name, and middle initial).\",\"group\":\"Patient & Insured Basic Info\",\"page_num\":0},{\"name\":\"Patient Birth Month\",\"description\":\"Enter the month of the patient’s date of birth.\",\"group\":\"Patient & Insured Basic Info\",\"page_num\":0},{\"name\":\"Patient Birth Day\",\"description\":\"Enter the day of the month of the patient’s date of birth.\",\"group\":\"Patient & Insured Basic Info\",\"page_num\":0},{\"name\":\"Patient Birth Year\",\"description\":\"Enter the year of the patient’s date of birth.\",\"group\":\"Patient & Insured Basic Info\",\"page_num\":0},{\"name\":\"Sex: Male\",\"description\":\"Check this box if the patient is male.\",\"group\":\"Patient & Insured Basic Info\",\"page_num\":0},{\"name\":\"Sex: Female\",\"description\":\"Check this box if the patient is female.\",\"group\":\"Patient & Insured Basic Info\",\"page_num\":0},{\"name\":\"Insured Name\",\"description\":\"Enter the insured person’s full name (last name, first name, and middle initial).\",\"group\":\"Patient & Insured Basic Info\",\"page_num\":0},{\"name\":\"Patient Street Address\",\"description\":\"Enter the patient's street address (house/building number and street name).\",\"group\":\"Patient Address & Phone\",\"page_num\":0},{\"name\":\"Patient City\",\"description\":\"Enter the city where the patient lives.\",\"group\":\"Patient Address & Phone\",\"page_num\":0},{\"name\":\"Patient State\",\"description\":\"Enter the state where the patient lives.\",\"group\":\"Patient Address & Phone\",\"page_num\":0},{\"name\":\"Patient ZIP Code\",\"description\":\"Enter the patient's ZIP or postal code.\",\"group\":\"Patient Address & Phone\",\"page_num\":0},{\"name\":\"Patient Telephone (Area Code)\",\"description\":\"Enter the area code for the patient's telephone number.\",\"group\":\"Patient Address & Phone\",\"page_num\":0},{\"name\":\"Patient Telephone Number\",\"description\":\"Enter the patient's telephone number.\",\"group\":\"Patient Address & Phone\",\"page_num\":0},{\"name\":\"Self\",\"description\":\"Check this box if the patient is the insured person (the policyholder).\",\"group\":\"Patient Relationship to Insured\",\"page_num\":0},{\"name\":\"Spouse\",\"description\":\"Check this box if the patient is the insured person’s spouse.\",\"group\":\"Patient Relationship to Insured\",\"page_num\":0},{\"name\":\"Child\",\"description\":\"Check this box if the patient is the insured person’s child (dependent).\",\"group\":\"Patient Relationship to Insured\",\"page_num\":0},{\"name\":\"Other\",\"description\":\"Check this box if the patient’s relationship to the insured is not self, spouse, or child.\",\"group\":\"Patient Relationship to Insured\",\"page_num\":0},{\"name\":\"Insured Street Address\",\"description\":\"Enter the insured’s street address (number and street name).\",\"group\":\"Insured Address & Phone\",\"page_num\":0},{\"name\":\"Insured City\",\"description\":\"Enter the city for the insured’s mailing address.\",\"group\":\"Insured Address & Phone\",\"page_num\":0},{\"name\":\"Insured State\",\"description\":\"Enter the state for the insured’s mailing address.\",\"group\":\"Insured Address & Phone\",\"page_num\":0},{\"name\":\"Insured ZIP Code\",\"description\":\"Enter the ZIP code for the insured’s mailing address.\",\"group\":\"Insured Address & Phone\",\"page_num\":0},{\"name\":\"Insured Phone Area Code\",\"description\":\"Enter the area code for the insured’s telephone number.\",\"group\":\"Insured Address & Phone\",\"page_num\":0},{\"name\":\"Insured Phone Number\",\"description\":\"Enter the insured’s telephone number excluding the area code.\",\"group\":\"Insured Address & Phone\",\"page_num\":0},{\"name\":\"NUCC Use (Item 8)\",\"description\":\"Enter any code or information provided by NUCC for Item 8, if applicable; otherwise leave blank.\",\"group\":\"Reserved for NUCC Use (Item 8)\",\"page_num\":0},{\"name\":\"Other Insured Name\",\"description\":\"Enter the other insured person’s full name (last name, first name, middle initial) as it appears on their insurance card. Fill only if 'Yes' is 'Yes'.\",\"group\":\"Other Insured Information\",\"page_num\":0},{\"name\":\"Other Insured Policy/Group Number\",\"description\":\"Enter the policy number or group number for the other insured person’s health plan. Fill only if 'Yes' is 'Yes'.\",\"group\":\"Other Insured Information\",\"page_num\":0},{\"name\":\"Reserved for NUCC Use (9b)\",\"description\":\"Enter the value requested for this reserved NUCC field, if instructed to do so by the payer. Fill only if 'Yes' is 'Yes'.\",\"group\":\"Other Insured Information\",\"page_num\":0},{\"name\":\"Reserved for NUCC Use (9c)\",\"description\":\"Enter the value requested for this reserved NUCC field, if instructed to do so by the payer. Fill only if 'Yes' is 'Yes'.\",\"group\":\"Other Insured Information\",\"page_num\":0},{\"name\":\"Other Insurance Plan/Program Name\",\"description\":\"Enter the name of the other insured person’s insurance plan or program. Fill only if 'Yes' is 'Yes'.\",\"group\":\"Other Insured Information\",\"page_num\":0},{\"name\":\"Employment? (Current or Previous) — Yes\",\"description\":\"Check this box if the patient’s condition is related to current or previous employment.\",\"group\":\"Patient Condition Related To (Employment/Accidents)\",\"page_num\":0},{\"name\":\"Employment? (Current or Previous) — No\",\"description\":\"Check this box if the patient’s condition is not related to current or previous employment.\",\"group\":\"Patient Condition Related To (Employment/Accidents)\",\"page_num\":0},{\"name\":\"Auto Accident? — Yes\",\"description\":\"Check this box if the patient’s condition is related to an automobile accident.\",\"group\":\"Patient Condition Related To (Employment/Accidents)\",\"page_num\":0},{\"name\":\"Auto Accident? — No\",\"description\":\"Check this box if the patient’s condition is not related to an automobile accident.\",\"group\":\"Patient Condition Related To (Employment/Accidents)\",\"page_num\":0},{\"name\":\"Auto Accident Location (State)\",\"description\":\"Enter the U.S. state where the auto accident occurred, if the patient’s condition is related to an auto accident. Fill only if 'Auto Accident? — Yes' is 'Yes'.\",\"group\":\"Patient Condition Related To (Employment/Accidents)\",\"page_num\":0},{\"name\":\"Other Accident? — Yes\",\"description\":\"Check this box if the patient’s condition is related to an accident other than an auto accident.\",\"group\":\"Patient Condition Related To (Employment/Accidents)\",\"page_num\":0},{\"name\":\"Other Accident? — No\",\"description\":\"Check this box if the patient’s condition is not related to any accident other than an auto accident.\",\"group\":\"Patient Condition Related To (Employment/Accidents)\",\"page_num\":0},{\"name\":\"Claim Codes (10d)\",\"description\":\"Enter any applicable claim codes for this claim as designated by the NUCC.\",\"group\":\"Claim Codes (10d)\",\"page_num\":0},{\"name\":\"Insured Policy Group or FECA Number\",\"description\":\"Enter the insured person’s policy group number or FECA number as shown on the insurance information.\",\"group\":\"Insured Policy & Demographics\",\"page_num\":0},{\"name\":\"Insured Date of Birth (Month)\",\"description\":\"Enter the month of the insured person’s date of birth.\",\"group\":\"Insured Policy & Demographics\",\"page_num\":0},{\"name\":\"Insured Date of Birth (Day)\",\"description\":\"Enter the day of the month of the insured person’s date of birth.\",\"group\":\"Insured Policy & Demographics\",\"page_num\":0},{\"name\":\"Insured Date of Birth (Year)\",\"description\":\"Enter the year of the insured person’s date of birth.\",\"group\":\"Insured Policy & Demographics\",\"page_num\":0},{\"name\":\"Sex - Male (M)\",\"description\":\"Check this box if the insured person is male.\",\"group\":\"Insured Policy & Demographics\",\"page_num\":0},{\"name\":\"Sex - Female (F)\",\"description\":\"Check this box if the insured person is female.\",\"group\":\"Insured Policy & Demographics\",\"page_num\":0},{\"name\":\"Other Claim ID Qualifier\",\"description\":\"Enter the qualifier code that identifies the type/source of the other claim ID.\",\"group\":\"Other Claim ID & Plan Name\",\"page_num\":0},{\"name\":\"Other Claim ID\",\"description\":\"Enter the other claim identification number associated with the patient’s coverage.\",\"group\":\"Other Claim ID & Plan Name\",\"page_num\":0},{\"name\":\"Other Insurance Plan Name\",\"description\":\"Enter the name of the other insurance plan or program related to the other claim.\",\"group\":\"Other Claim ID & Plan Name\",\"page_num\":0},{\"name\":\"Yes\",\"description\":\"Check this box if the patient is covered by another health benefit plan in addition to the plan listed on this claim.\",\"group\":\"Another Health Benefit Plan (11d)\",\"page_num\":0},{\"name\":\"No\",\"description\":\"Check this box if the patient is not covered by any other health benefit plan besides the plan listed on this claim.\",\"group\":\"Another Health Benefit Plan (11d)\",\"page_num\":0},{\"name\":\"Patient/Authorized Person Signature\",\"description\":\"Enter the signature of the patient or the authorized person who is signing to authorize release of information and payment of benefits.\",\"group\":\"Patient/Insured Signatures & Dates\",\"page_num\":0},{\"name\":\"Signature Date (Patient/Authorized Person)\",\"description\":\"Enter the date the patient or authorized person signed the form.\",\"group\":\"Patient/Insured Signatures & Dates\",\"page_num\":0},{\"name\":\"Insured/Authorized Person Signature\",\"description\":\"Enter the signature of the insured or authorized person authorizing payment of medical benefits to the provider or supplier.\",\"group\":\"Patient/Insured Signatures & Dates\",\"page_num\":0},{\"name\":\"Current Illness/Injury Date - Month\",\"description\":\"Enter the month of the date of current illness, injury, or pregnancy (LMP).\",\"group\":\"Illness/Injury/Other Dates (Items 14-15)\",\"page_num\":0},{\"name\":\"Current Illness/Injury Date - Day\",\"description\":\"Enter the day of the date of current illness, injury, or pregnancy (LMP).\",\"group\":\"Illness/Injury/Other Dates (Items 14-15)\",\"page_num\":0},{\"name\":\"Current Illness/Injury Date - Year\",\"description\":\"Enter the year of the date of current illness, injury, or pregnancy (LMP).\",\"group\":\"Illness/Injury/Other Dates (Items 14-15)\",\"page_num\":0},{\"name\":\"Current Illness/Injury Date Qualifier\",\"description\":\"Enter the qualifier code that indicates what the date of current illness, injury, or pregnancy represents.\",\"group\":\"Illness/Injury/Other Dates (Items 14-15)\",\"page_num\":0},{\"name\":\"Other Date Qualifier\",\"description\":\"Enter the qualifier code that indicates what the other date represents.\",\"group\":\"Illness/Injury/Other Dates (Items 14-15)\",\"page_num\":0},{\"name\":\"Other Date - Month\",\"description\":\"Enter the month for the other date indicated by the qualifier.\",\"group\":\"Illness/Injury/Other Dates (Items 14-15)\",\"page_num\":0},{\"name\":\"Other Date - Day\",\"description\":\"Enter the day for the other date indicated by the qualifier.\",\"group\":\"Illness/Injury/Other Dates (Items 14-15)\",\"page_num\":0},{\"name\":\"Other Date - Year\",\"description\":\"Enter the year for the other date indicated by the qualifier.\",\"group\":\"Illness/Injury/Other Dates (Items 14-15)\",\"page_num\":0},{\"name\":\"Unable to Work From (Month)\",\"description\":\"Enter the month when the patient first became unable to work in their current occupation.\",\"group\":\"Unable to Work Dates (Item 16)\",\"page_num\":0},{\"name\":\"Unable to Work From (Day)\",\"description\":\"Enter the day of the month when the patient first became unable to work in their current occupation.\",\"group\":\"Unable to Work Dates (Item 16)\",\"page_num\":0},{\"name\":\"Unable to Work From (Year)\",\"description\":\"Enter the year when the patient first became unable to work in their current occupation.\",\"group\":\"Unable to Work Dates (Item 16)\",\"page_num\":0},{\"name\":\"Unable to Work To (Month)\",\"description\":\"Enter the month when the patient returned to work (or the end month of the period they were unable to work).\",\"group\":\"Unable to Work Dates (Item 16)\",\"page_num\":0},{\"name\":\"Unable to Work To (Day)\",\"description\":\"Enter the day of the month when the patient returned to work (or the end day of the period they were unable to work).\",\"group\":\"Unable to Work Dates (Item 16)\",\"page_num\":0},{\"name\":\"Unable to Work To (Year)\",\"description\":\"Enter the year when the patient returned to work (or the end year of the period they were unable to work).\",\"group\":\"Unable to Work Dates (Item 16)\",\"page_num\":0},{\"name\":\"Referring provider last name\",\"description\":\"Enter the referring provider’s last name.\",\"group\":\"Referring Provider Information (Item 17)\",\"page_num\":0},{\"name\":\"Referring provider first name\",\"description\":\"Enter the referring provider’s first name (and middle initial if applicable).\",\"group\":\"Referring Provider Information (Item 17)\",\"page_num\":0},{\"name\":\"Referring provider ID qualifier (17a)\",\"description\":\"Enter the qualifier that identifies the type of non-NPI referring provider ID reported in Item 17a.\",\"group\":\"Referring Provider Information (Item 17)\",\"page_num\":0},{\"name\":\"Referring provider ID number (17a)\",\"description\":\"Enter the referring provider’s non-NPI identification number corresponding to the qualifier in Item 17a.\",\"group\":\"Referring Provider Information (Item 17)\",\"page_num\":0},{\"name\":\"Referring provider NPI (17b)\",\"description\":\"Enter the referring provider’s National Provider Identifier (NPI).\",\"group\":\"Referring Provider Information (Item 17)\",\"page_num\":0},{\"name\":\"Hospitalization From - Month\",\"description\":\"Enter the month the hospitalization began (FROM date).\",\"group\":\"Hospitalization Dates (Item 18)\",\"page_num\":0},{\"name\":\"Hospitalization From - Day\",\"description\":\"Enter the day of the month the hospitalization began (FROM date).\",\"group\":\"Hospitalization Dates (Item 18)\",\"page_num\":0},{\"name\":\"Hospitalization From - Year\",\"description\":\"Enter the year the hospitalization began (FROM date).\",\"group\":\"Hospitalization Dates (Item 18)\",\"page_num\":0},{\"name\":\"Hospitalization To - Month\",\"description\":\"Enter the month the hospitalization ended (TO date). Fill only if 'Hospitalization From - Day' is 'Yes'.\",\"group\":\"Hospitalization Dates (Item 18)\",\"page_num\":0},{\"name\":\"Hospitalization To - Day\",\"description\":\"Enter the day of the month the hospitalization ended (TO date).\",\"group\":\"Hospitalization Dates (Item 18)\",\"page_num\":0},{\"name\":\"Hospitalization To - Year\",\"description\":\"Enter the year the hospitalization ended (TO date).\",\"group\":\"Hospitalization Dates (Item 18)\",\"page_num\":0},{\"name\":\"Additional Claim Information\",\"description\":\"Enter any additional claim information or remarks designated by NUCC that apply to this claim.\",\"group\":\"Additional Claim Info & Outside Lab (Items 19-20)\",\"page_num\":0},{\"name\":\"Outside Lab: Yes\",\"description\":\"Check this box if the lab work for this claim was performed by an outside (non-office) laboratory.\",\"group\":\"Additional Claim Info & Outside Lab (Items 19-20)\",\"page_num\":0},{\"name\":\"Outside Lab: No\",\"description\":\"Check this box if the lab work for this claim was not performed by an outside laboratory.\",\"group\":\"Additional Claim Info & Outside Lab (Items 19-20)\",\"page_num\":0},{\"name\":\"Outside Lab Indicator\",\"description\":\"Indicate whether the services were performed by an outside laboratory (e.g., enter Yes or No).\",\"group\":\"Additional Claim Info & Outside Lab (Items 19-20)\",\"page_num\":0},{\"name\":\"Outside Lab Charges\",\"description\":\"Enter the total charges amount for services performed by an outside laboratory.\",\"group\":\"Additional Claim Info & Outside Lab (Items 19-20)\",\"page_num\":0},{\"name\":\"ICD Indicator\",\"description\":\"Enter the ICD code set indicator that applies to the diagnosis codes listed (as required by the form).\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Diagnosis Code A\",\"description\":\"Enter the primary diagnosis code (A) describing the patient’s illness or injury.\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Diagnosis Code B\",\"description\":\"Enter diagnosis code B describing the patient’s illness or injury.\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Diagnosis Code C\",\"description\":\"Enter diagnosis code C describing the patient’s illness or injury.\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Diagnosis Code D\",\"description\":\"Enter diagnosis code D describing the patient’s illness or injury.\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Diagnosis Code E\",\"description\":\"Enter diagnosis code E describing the patient’s illness or injury.\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Diagnosis Code F\",\"description\":\"Enter diagnosis code F describing the patient’s illness or injury.\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Diagnosis Code G\",\"description\":\"Enter diagnosis code G describing the patient’s illness or injury.\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Diagnosis Code H\",\"description\":\"Enter diagnosis code H describing the patient’s illness or injury.\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Diagnosis Code I\",\"description\":\"Enter diagnosis code I describing the patient’s illness or injury.\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Diagnosis Code J\",\"description\":\"Enter diagnosis code J describing the patient’s illness or injury.\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Diagnosis Code K\",\"description\":\"Enter diagnosis code K describing the patient’s illness or injury.\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Diagnosis Code L\",\"description\":\"Enter diagnosis code L describing the patient’s illness or injury.\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Diagnosis Code M\",\"description\":\"Enter an additional diagnosis code (M) describing the patient’s illness or injury, if applicable.\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Resubmission Code\",\"description\":\"Enter the code that indicates this claim is a resubmission or corrected/replacement claim, if applicable.\",\"group\":\"Resubmission & Original Reference (Item 22)\",\"page_num\":0},{\"name\":\"Original Reference Number\",\"description\":\"Enter the reference number or identifier for the original claim being resubmitted or corrected.\",\"group\":\"Resubmission & Original Reference (Item 22)\",\"page_num\":0},{\"name\":\"Prior Authorization Number\",\"description\":\"Enter the prior authorization number issued for the services being claimed (Item 23).\",\"group\":\"Prior Authorization Number (Item 23)\",\"page_num\":0},{\"name\":\"Service From Month\",\"description\":\"Enter the month of the start date of service for this service line.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Service From Day\",\"description\":\"Enter the day of the start date of service for this service line.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Service From Year\",\"description\":\"Enter the year of the start date of service for this service line.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Service To Month\",\"description\":\"Enter the month of the end date of service for this service line, if applicable.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Service To Day\",\"description\":\"Enter the day of the end date of service for this service line, if applicable.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Service To Year\",\"description\":\"Enter the year of the end date of service for this service line, if applicable.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Place of Service\",\"description\":\"Enter the place of service code that indicates where the service was provided.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Emergency Indicator\",\"description\":\"Enter the emergency indicator value for this service line, if required.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Procedure Code (CPT/HCPCS)\",\"description\":\"Enter the CPT or HCPCS procedure code for the service provided.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Modifier 1\",\"description\":\"Enter the first procedure modifier, if applicable.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Modifier 2\",\"description\":\"Enter the second procedure modifier, if applicable.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Modifier 3\",\"description\":\"Enter the third procedure modifier, if applicable.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Modifier 4\",\"description\":\"Enter the fourth procedure modifier, if applicable.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Diagnosis Pointer\",\"description\":\"Enter the diagnosis code reference(s) (pointer) that apply to this procedure.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Line Item Charges\",\"description\":\"Enter the total charge amount for this service line.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Days or Units\",\"description\":\"Enter the number of days or units billed for this service line.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"EPSDT/Family Plan\",\"description\":\"Enter the EPSDT or family planning indicator/code, if applicable.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Rendering Provider ID Qualifier\",\"description\":\"Enter the qualifier that identifies the type of non-NPI rendering provider identifier being reported.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Rendering Provider NPI\",\"description\":\"Enter the rendering provider’s National Provider Identifier (NPI) for this service line.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Row 1 — 24J Rendering Provider ID #\",\"description\":\"Enter the rendering provider's identifier for Row 1 (24J), for example the provider's NPI or other assigned ID.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Rendering Provider Other ID\",\"description\":\"Enter the rendering provider’s non-NPI identifier for this service line, if applicable.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Service Date From (Month)\",\"description\":\"Enter the month portion of the beginning date of service for the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Service Date From (Day)\",\"description\":\"Enter the day portion of the beginning date of service for the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Service Date From (Year)\",\"description\":\"Enter the year portion of the beginning date of service for the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Service Date To (Month)\",\"description\":\"Enter the month portion of the ending date of service for the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Service Date To (Day)\",\"description\":\"Enter the day portion of the ending date of service for the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Service Date To (Year)\",\"description\":\"Enter the year portion of the ending date of service for the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Place of Service Code\",\"description\":\"Enter the place of service code that identifies where the services were provided for the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Emergency Indicator (EMG)\",\"description\":\"Enter the emergency indicator value for the second service line, if applicable.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Procedure Code (CPT/HCPCS)\",\"description\":\"Enter the CPT or HCPCS procedure/service code for the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Procedure Modifier 1\",\"description\":\"Enter the first procedure modifier associated with the procedure code for the second service line, if any.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Procedure Modifier 2\",\"description\":\"Enter the second procedure modifier associated with the procedure code for the second service line, if any.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Procedure Modifier 3\",\"description\":\"Enter the third procedure modifier associated with the procedure code for the second service line, if any.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Procedure Modifier 4\",\"description\":\"Enter the fourth procedure modifier associated with the procedure code for the second service line, if any.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Diagnosis Pointer\",\"description\":\"Enter the diagnosis pointer(s) that link this service to the relevant diagnosis code(s) for the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Line Item Charge Amount\",\"description\":\"Enter the total charge amount being billed for the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Days or Units\",\"description\":\"Enter the number of days or units for the billed service on the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"EPSDT Indicator\",\"description\":\"Enter the EPSDT indicator value for the second service line, if applicable.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Family Planning Indicator\",\"description\":\"Enter the family planning indicator value for the second service line, if applicable.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Rendering Provider ID Qualifier\",\"description\":\"Enter the qualifier that identifies the type of rendering provider identifier reported for the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Rendering Provider NPI\",\"description\":\"Enter the rendering provider's NPI for the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Rendering Provider Other ID\",\"description\":\"Enter the rendering provider's other identifier (non-NPI), if applicable, for the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"From Date of Service - Month\",\"description\":\"Enter the month of the start (FROM) date of service for this third service line.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"From Date of Service - Day\",\"description\":\"Enter the day of the start (FROM) date of service for this third service line.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"From Date of Service - Year\",\"description\":\"Enter the year of the start (FROM) date of service for this third service line.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"To Date of Service - Month\",\"description\":\"Enter the month of the end (TO) date of service for this third service line, if different from the from date.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"To Date of Service - Day\",\"description\":\"Enter the day of the end (TO) date of service for this third service line, if different from the from date.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"To Date of Service - Year\",\"description\":\"Enter the year of the end (TO) date of service for this third service line, if different from the from date.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Place of Service\",\"description\":\"Enter the place of service code for where the service was performed on this third service line.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Emergency Indicator\",\"description\":\"Enter the emergency indicator for this third service line, if applicable.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Procedure/Service Code (CPT/HCPCS)\",\"description\":\"Enter the CPT/HCPCS procedure or service code billed on this third service line.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Modifier 1\",\"description\":\"Enter the first procedure modifier for the CPT/HCPCS code on this third service line, if applicable.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Modifier 2\",\"description\":\"Enter the second procedure modifier for the CPT/HCPCS code on this third service line, if applicable.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Modifier 3\",\"description\":\"Enter the third procedure modifier for the CPT/HCPCS code on this third service line, if applicable.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Modifier 4\",\"description\":\"Enter the fourth procedure modifier for the CPT/HCPCS code on this third service line, if applicable.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Diagnosis Pointer\",\"description\":\"Enter the diagnosis code reference letter(s) (from Item 21) that apply to this third service line.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Charges - Dollars\",\"description\":\"Enter the dollar amount charged for this third service line.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Charges - Cents\",\"description\":\"Enter the cents portion of the amount charged for this third service line.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Days or Units\",\"description\":\"Enter the number of days or units for the service billed on this third service line.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"EPSDT/Family Plan\",\"description\":\"Enter the EPSDT/Family Plan indicator for this third service line, if applicable.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Rendering Provider ID Qualifier\",\"description\":\"Enter the qualifier that identifies the type of non-NPI rendering provider identifier reported for this third service line, if applicable.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Rendering Provider NPI\",\"description\":\"Enter the rendering provider's NPI for this third service line.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Rendering Provider Other ID\",\"description\":\"Enter the rendering provider's non-NPI identifier for this third service line, if applicable.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Service Line 4 From Date (MM)\",\"description\":\"Enter the month of the start date for the service period on this service line.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 From Date (DD)\",\"description\":\"Enter the day of the start date for the service period on this service line.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 From Date (YY)\",\"description\":\"Enter the two-digit year of the start date for the service period on this service line.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 To Date (MM)\",\"description\":\"Enter the month of the end date for the service period on this service line.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 To Date (DD)\",\"description\":\"Enter the day of the end date for the service period on this service line.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 To Date (YY)\",\"description\":\"Enter the two-digit year of the end date for the service period on this service line.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Place of Service\",\"description\":\"Enter the place of service code that describes where the service was provided for this service line.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Emergency Indicator\",\"description\":\"Enter the emergency indicator value for this service line, if applicable.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Procedure Code (CPT/HCPCS)\",\"description\":\"Enter the CPT/HCPCS procedure code for the service or item billed on this service line.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Modifier 1\",\"description\":\"Enter the first procedure modifier associated with the billed procedure code on this service line, if any.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Modifier 2\",\"description\":\"Enter the second procedure modifier associated with the billed procedure code on this service line, if any.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Modifier 3\",\"description\":\"Enter the third procedure modifier associated with the billed procedure code on this service line, if any.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Modifier 4\",\"description\":\"Enter the fourth procedure modifier associated with the billed procedure code on this service line, if any.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Diagnosis Pointer\",\"description\":\"Enter the diagnosis pointer(s) that link this service line to the diagnosis code(s) listed in the diagnosis section.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Charges\",\"description\":\"Enter the total charge amount being billed for this service line.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Days or Units\",\"description\":\"Enter the number of days or units for the service billed on this service line.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 EPSDT/Family Plan\",\"description\":\"Enter the EPSDT or family planning indicator for this service line, if applicable.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Provider ID Qualifier\",\"description\":\"Enter the qualifier that identifies the type of provider ID reported for this service line, if applicable.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Rendering Provider ID (Non-NPI)\",\"description\":\"Enter the rendering provider's non-NPI identifier for this service line, if required by the payer.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Rendering Provider NPI\",\"description\":\"Enter the rendering provider's National Provider Identifier (NPI) for this service line.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Rendering Provider NPI (Alternate Box)\",\"description\":\"Enter the rendering provider's National Provider Identifier (NPI) for this service line if the form uses this second identifier box.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"From Date of Service - Month\",\"description\":\"Enter the month portion of the start date for this fifth service line.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"From Date of Service - Day\",\"description\":\"Enter the day portion of the start date for this fifth service line.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"From Date of Service - Year\",\"description\":\"Enter the year portion of the start date for this fifth service line.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"To Date of Service - Month\",\"description\":\"Enter the month portion of the end date for this fifth service line (if different from the from date).\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"To Date of Service - Day\",\"description\":\"Enter the day portion of the end date for this fifth service line (if different from the from date).\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"To Date of Service - Year\",\"description\":\"Enter the year portion of the end date for this fifth service line (if different from the from date).\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Place of Service\",\"description\":\"Enter the place of service code for where the service was provided on this fifth service line.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Emergency Indicator (EMG)\",\"description\":\"Enter the emergency indicator value for this fifth service line, if applicable.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Procedure/Service Code (CPT/HCPCS)\",\"description\":\"Enter the CPT/HCPCS procedure or service code for this fifth service line.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Modifier 1\",\"description\":\"Enter the first procedure modifier associated with the CPT/HCPCS code on this fifth service line, if any.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Modifier 2\",\"description\":\"Enter the second procedure modifier associated with the CPT/HCPCS code on this fifth service line, if any.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Modifier 3\",\"description\":\"Enter the third procedure modifier associated with the CPT/HCPCS code on this fifth service line, if any.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Modifier 4\",\"description\":\"Enter the fourth procedure modifier associated with the CPT/HCPCS code on this fifth service line, if any.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Diagnosis Pointer\",\"description\":\"Enter the diagnosis pointer(s) (letters/numbers that reference the diagnoses listed in Item 21) that apply to this fifth service line.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Line Item Charges\",\"description\":\"Enter the charge amount billed for this fifth service line.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Days or Units\",\"description\":\"Enter the number of days or units for the service billed on this fifth service line.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"EPSDT Indicator\",\"description\":\"Enter the EPSDT indicator value for this fifth service line, if applicable.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Family Plan Indicator\",\"description\":\"Enter the family plan indicator value for this fifth service line, if applicable.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Rendering Provider ID Qualifier\",\"description\":\"Enter the qualifier that identifies the type of rendering provider ID reported for this fifth service line.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Rendering Provider ID (Non-NPI)\",\"description\":\"Enter the rendering provider's non-NPI identifier for this fifth service line, if required.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Rendering Provider NPI\",\"description\":\"Enter the rendering provider's National Provider Identifier (NPI) for this fifth service line.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Service Line 6 From Date (Month)\",\"description\":\"Enter the month of the beginning date of service for the sixth service line.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 From Date (Day)\",\"description\":\"Enter the day of the beginning date of service for the sixth service line.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 From Date (Year)\",\"description\":\"Enter the year of the beginning date of service for the sixth service line.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 To Date (Month)\",\"description\":\"Enter the month of the ending date of service for the sixth service line.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 To Date (Day)\",\"description\":\"Enter the day of the ending date of service for the sixth service line.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 To Date (Year)\",\"description\":\"Enter the year of the ending date of service for the sixth service line.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 Place of Service Code\",\"description\":\"Enter the place of service code that identifies where the service was provided for the sixth service line.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 EMG Indicator\",\"description\":\"Enter the emergency indicator value for the sixth service line, if applicable.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 CPT/HCPCS Code\",\"description\":\"Enter the CPT or HCPCS procedure code for the service billed on the sixth service line.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 Modifier 1\",\"description\":\"Enter the first procedure modifier that applies to the CPT/HCPCS code on the sixth service line, if any.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 Modifier 2\",\"description\":\"Enter the second procedure modifier that applies to the CPT/HCPCS code on the sixth service line, if any.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 Modifier 3\",\"description\":\"Enter the third procedure modifier that applies to the CPT/HCPCS code on the sixth service line, if any.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 Modifier 4\",\"description\":\"Enter the fourth procedure modifier that applies to the CPT/HCPCS code on the sixth service line, if any.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 Diagnosis Pointer\",\"description\":\"Enter the diagnosis reference letter(s)/number(s) that link this service to the diagnoses listed in Item 21.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 Charge Amount\",\"description\":\"Enter the total charge amount being billed for the sixth service line.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 Days or Units\",\"description\":\"Enter the number of days or units for the service billed on the sixth service line.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 EPSDT Indicator\",\"description\":\"Enter the EPSDT indicator value for the sixth service line, if applicable.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 Family Plan Indicator\",\"description\":\"Enter the family plan indicator value for the sixth service line, if applicable.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 Rendering Provider ID Qualifier\",\"description\":\"Enter the qualifier that identifies the type of non-NPI rendering provider identifier reported for the sixth service line, if applicable.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 Rendering Provider Other ID\",\"description\":\"Enter the rendering provider’s non-NPI identifier for the sixth service line, if applicable.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 Rendering Provider NPI\",\"description\":\"Enter the rendering provider’s NPI for the sixth service line.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Federal Tax ID Number\",\"description\":\"Enter the billing provider’s Federal Tax Identification Number (TIN).\",\"group\":\"Tax ID, Patient Account & Claim Totals (Items 25-30)\",\"page_num\":0},{\"name\":\"Federal Tax ID Type: SSN\",\"description\":\"Check this box if the Federal Tax ID number entered in Item 25 is a Social Security Number (SSN).\",\"group\":\"Tax ID, Patient Account & Claim Totals (Items 25-30)\",\"page_num\":0},{\"name\":\"Federal Tax ID Type: EIN\",\"description\":\"Check this box if the Federal Tax ID number entered in Item 25 is an Employer Identification Number (EIN).\",\"group\":\"Tax ID, Patient Account & Claim Totals (Items 25-30)\",\"page_num\":0},{\"name\":\"Patient Account Number\",\"description\":\"Enter the patient’s account number used by the provider or facility to identify this claim.\",\"group\":\"Tax ID, Patient Account & Claim Totals (Items 25-30)\",\"page_num\":0},{\"name\":\"Accept Assignment: Yes\",\"description\":\"Check this box if the provider accepts assignment of benefits for this claim.\",\"group\":\"Tax ID, Patient Account & Claim Totals (Items 25-30)\",\"page_num\":0},{\"name\":\"Accept Assignment: No\",\"description\":\"Check this box if the provider does not accept assignment of benefits for this claim.\",\"group\":\"Tax ID, Patient Account & Claim Totals (Items 25-30)\",\"page_num\":0},{\"name\":\"Total Charge\",\"description\":\"Enter the total charges for all services reported on this claim.\",\"group\":\"Tax ID, Patient Account & Claim Totals (Items 25-30)\",\"page_num\":0},{\"name\":\"Amount Paid\",\"description\":\"Enter the amount already paid toward this claim by the patient and/or other sources.\",\"group\":\"Tax ID, Patient Account & Claim Totals (Items 25-30)\",\"page_num\":0},{\"name\":\"Reserved for NUCC Use (Part 1)\",\"description\":\"Enter any information required by NUCC or the payer for the first reserved segment of Item 30.\",\"group\":\"Tax ID, Patient Account & Claim Totals (Items 25-30)\",\"page_num\":0},{\"name\":\"Reserved for NUCC Use (Part 2)\",\"description\":\"Enter any information required by NUCC or the payer for the second reserved segment of Item 30.\",\"group\":\"Tax ID, Patient Account & Claim Totals (Items 25-30)\",\"page_num\":0},{\"name\":\"Reserved for NUCC Use (Part 3)\",\"description\":\"Enter any information required by NUCC or the payer for the third reserved segment of Item 30.\",\"group\":\"Tax ID, Patient Account & Claim Totals (Items 25-30)\",\"page_num\":0},{\"name\":\"Reserved for NUCC Use (Part 4)\",\"description\":\"Enter any information required by NUCC or the payer for the fourth reserved segment of Item 30.\",\"group\":\"Tax ID, Patient Account & Claim Totals (Items 25-30)\",\"page_num\":0},{\"name\":\"Physician/Supplier Signature\",\"description\":\"Enter the signature of the physician or supplier (including degrees or credentials) certifying the claim.\",\"group\":\"Physician/Supplier Signature (Item 31)\",\"page_num\":0},{\"name\":\"Signature Date\",\"description\":\"Enter the date the physician or supplier signed the claim.\",\"group\":\"Physician/Supplier Signature (Item 31)\",\"page_num\":0},{\"name\":\"Service Facility Name and Address\",\"description\":\"Enter the name and full address of the facility where the services were provided (street, city, state, and ZIP code).\",\"group\":\"Service Facility Location (Item 32)\",\"page_num\":0},{\"name\":\"Service Facility NPI\",\"description\":\"Enter the National Provider Identifier (NPI) for the service facility.\",\"group\":\"Service Facility Location (Item 32)\",\"page_num\":0},{\"name\":\"Service Facility Other ID\",\"description\":\"Enter any additional identification number for the service facility (if applicable).\",\"group\":\"Service Facility Location (Item 32)\",\"page_num\":0},{\"name\":\"Billing Provider Phone Area Code\",\"description\":\"Enter the area code portion of the billing provider’s phone number.\",\"group\":\"Billing Provider Info & Phone (Item 33)\",\"page_num\":0},{\"name\":\"Billing Provider Phone Number\",\"description\":\"Enter the remaining digits of the billing provider’s phone number.\",\"group\":\"Billing Provider Info & Phone (Item 33)\",\"page_num\":0},{\"name\":\"Billing Provider Name and Address\",\"description\":\"Enter the billing provider’s name and mailing address (and other identifying details as needed) as shown in Item 33.\",\"group\":\"Billing Provider Info & Phone (Item 33)\",\"page_num\":0},{\"name\":\"Billing Provider NPI (33a)\",\"description\":\"Enter the billing provider’s National Provider Identifier (NPI).\",\"group\":\"Billing Provider Info & Phone (Item 33)\",\"page_num\":0},{\"name\":\"Billing Provider Other ID (33b)\",\"description\":\"Enter the billing provider’s other identifier (if applicable) as required by the payer.\",\"group\":\"Billing Provider Info & Phone (Item 33)\",\"page_num\":0}]}},\"sourceToolAssistantUUID\":\"0722fad6-e6f0-4507-8d94-050abcd4e0cd\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"c:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"type\":\"last-prompt\",\"lastPrompt\":\"yes, re-run\",\"leafUuid\":\"6a8ed5e6-973c-475e-ae2c-b5839acc04ba\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\"}\n{\"type\":\"ai-title\",\"aiTitle\":\"View available workspace forms\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\"}\n{\"parentUuid\":\"6a8ed5e6-973c-475e-ae2c-b5839acc04ba\",\"isSidechain\":false,\"message\":{\"model\":\"claude-opus-4-8\",\"id\":\"msg_01XiPpEzj7WyNHAhpTcCK1wQ\",\"type\":\"message\",\"role\":\"assistant\",\"content\":[{\"type\":\"tool_use\",\"id\":\"toolu_015HnoQyQuhS4QePEC3U1QBx\",\"name\":\"Bash\",\"input\":{\"command\":\"python -c \\\"\\nimport json\\np=r'C:\\\\Users\\\\smirn\\\\.claude\\\\projects\\\\c--Users-smirn-OneDrive-Documents-GitHub-botmakers-projects-copilot-us-instafill-ai\\\\986638d6-b238-4e02-83a0-449ec3df5830\\\\tool-results\\\\toolu_01SbGa1BPyFBBbXNizN4xJoo.txt'\\nd=json.load(open(p,encoding='utf-8'))\\nfor f in d['fields']:\\n if 'phone' in f['name'].lower() or 'telephone' in f['name'].lower():\\n print(repr(f['name']),'=>',repr(f.get('value')))\\n\\\"\",\"description\":\"Check phone field values in filled data\"},\"caller\":{\"type\":\"direct\"}}],\"stop_reason\":\"tool_use\",\"stop_sequence\":null,\"stop_details\":null,\"usage\":{\"input_tokens\":2,\"cache_creation_input_tokens\":1165,\"cache_read_input_tokens\":51679,\"output_tokens\":301,\"server_tool_use\":{\"web_search_requests\":0,\"web_fetch_requests\":0},\"service_tier\":\"standard\",\"cache_creation\":{\"ephemeral_1h_input_tokens\":1165,\"ephemeral_5m_input_tokens\":0},\"inference_geo\":\"not_available\",\"iterations\":[{\"input_tokens\":2,\"output_tokens\":301,\"cache_read_input_tokens\":51679,\"cache_creation_input_tokens\":1165,\"cache_creation\":{\"ephemeral_5m_input_tokens\":0,\"ephemeral_1h_input_tokens\":1165},\"type\":\"message\"}],\"speed\":\"standard\"},\"diagnostics\":null},\"requestId\":\"req_011Cc7Q9yJDjh1xdhL49Xh1R\",\"attributionMcpServer\":\"claude.ai Instafill\",\"attributionMcpTool\":\"get_filled_form_data\",\"type\":\"assistant\",\"uuid\":\"165285de-8e84-4ab2-bf72-ee505f885fa9\",\"timestamp\":\"2026-06-16T18:19:18.896Z\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"c:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"parentUuid\":\"165285de-8e84-4ab2-bf72-ee505f885fa9\",\"isSidechain\":false,\"promptId\":\"ee4d1f2e-e39b-411a-8c3b-307951e229ea\",\"type\":\"user\",\"message\":{\"role\":\"user\",\"content\":[{\"tool_use_id\":\"toolu_015HnoQyQuhS4QePEC3U1QBx\",\"type\":\"tool_result\",\"content\":\"'Patient Telephone (Area Code)' => None\\r\\n'Patient Telephone Number' => None\\r\\n'Insured Phone Area Code' => None\\r\\n'Insured Phone Number' => None\\r\\n'Billing Provider Phone Area Code' => None\\r\\n'Billing Provider Phone Number' => None\",\"is_error\":false}]},\"uuid\":\"5a5575e6-d3b7-437f-98b7-6462ff4fd1cc\",\"timestamp\":\"2026-06-16T18:19:31.878Z\",\"toolUseResult\":{\"stdout\":\"'Patient Telephone (Area Code)' => None\\r\\n'Patient Telephone Number' => None\\r\\n'Insured Phone Area Code' => None\\r\\n'Insured Phone Number' => None\\r\\n'Billing Provider Phone Area Code' => None\\r\\n'Billing Provider Phone Number' => None\",\"stderr\":\"\",\"interrupted\":false,\"isImage\":false,\"noOutputExpected\":false},\"sourceToolAssistantUUID\":\"165285de-8e84-4ab2-bf72-ee505f885fa9\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"C:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"parentUuid\":\"5a5575e6-d3b7-437f-98b7-6462ff4fd1cc\",\"isSidechain\":false,\"message\":{\"model\":\"claude-opus-4-8\",\"id\":\"msg_01HoxhqGkZMZ1GzuaQzoUwdK\",\"type\":\"message\",\"role\":\"assistant\",\"content\":[{\"type\":\"thinking\",\"thinking\":\"\",\"signature\":\"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\"}],\"stop_reason\":\"tool_use\",\"stop_sequence\":null,\"stop_details\":null,\"usage\":{\"input_tokens\":2,\"cache_creation_input_tokens\":399,\"cache_read_input_tokens\":52844,\"output_tokens\":432,\"server_tool_use\":{\"web_search_requests\":0,\"web_fetch_requests\":0},\"service_tier\":\"standard\",\"cache_creation\":{\"ephemeral_1h_input_tokens\":399,\"ephemeral_5m_input_tokens\":0},\"inference_geo\":\"not_available\",\"iterations\":[{\"input_tokens\":2,\"output_tokens\":432,\"cache_read_input_tokens\":52844,\"cache_creation_input_tokens\":399,\"cache_creation\":{\"ephemeral_5m_input_tokens\":0,\"ephemeral_1h_input_tokens\":399},\"type\":\"message\"}],\"speed\":\"standard\"},\"diagnostics\":null},\"requestId\":\"req_011Cc7QBF5XBnnP7cqBpGRVX\",\"attributionMcpServer\":\"claude.ai Instafill\",\"attributionMcpTool\":\"get_filled_form_data\",\"type\":\"assistant\",\"uuid\":\"c244540b-72c4-4db2-8b2c-1164490a8e60\",\"timestamp\":\"2026-06-16T18:19:34.572Z\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"C:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"parentUuid\":\"c244540b-72c4-4db2-8b2c-1164490a8e60\",\"isSidechain\":false,\"message\":{\"model\":\"claude-opus-4-8\",\"id\":\"msg_01HoxhqGkZMZ1GzuaQzoUwdK\",\"type\":\"message\",\"role\":\"assistant\",\"content\":[{\"type\":\"text\",\"text\":\"Value isn't under `value` — let me check the actual keys.\"}],\"stop_reason\":\"tool_use\",\"stop_sequence\":null,\"stop_details\":null,\"usage\":{\"input_tokens\":2,\"cache_creation_input_tokens\":399,\"cache_read_input_tokens\":52844,\"output_tokens\":432,\"server_tool_use\":{\"web_search_requests\":0,\"web_fetch_requests\":0},\"service_tier\":\"standard\",\"cache_creation\":{\"ephemeral_1h_input_tokens\":399,\"ephemeral_5m_input_tokens\":0},\"inference_geo\":\"not_available\",\"iterations\":[{\"input_tokens\":2,\"output_tokens\":432,\"cache_read_input_tokens\":52844,\"cache_creation_input_tokens\":399,\"cache_creation\":{\"ephemeral_5m_input_tokens\":0,\"ephemeral_1h_input_tokens\":399},\"type\":\"message\"}],\"speed\":\"standard\"},\"diagnostics\":null},\"requestId\":\"req_011Cc7QBF5XBnnP7cqBpGRVX\",\"attributionMcpServer\":\"claude.ai Instafill\",\"attributionMcpTool\":\"get_filled_form_data\",\"type\":\"assistant\",\"uuid\":\"05cfd340-8860-4c1c-b21d-20cd4d93e487\",\"timestamp\":\"2026-06-16T18:19:35.105Z\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"C:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"parentUuid\":\"05cfd340-8860-4c1c-b21d-20cd4d93e487\",\"isSidechain\":false,\"message\":{\"model\":\"claude-opus-4-8\",\"id\":\"msg_01HoxhqGkZMZ1GzuaQzoUwdK\",\"type\":\"message\",\"role\":\"assistant\",\"content\":[{\"type\":\"tool_use\",\"id\":\"toolu_015eVKXksRuDGsMzD9uYn7Gr\",\"name\":\"Bash\",\"input\":{\"command\":\"python -c \\\"\\nimport json\\np=r'C:\\\\Users\\\\smirn\\\\.claude\\\\projects\\\\c--Users-smirn-OneDrive-Documents-GitHub-botmakers-projects-copilot-us-instafill-ai\\\\986638d6-b238-4e02-83a0-449ec3df5830\\\\tool-results\\\\toolu_01SbGa1BPyFBBbXNizN4xJoo.txt'\\nd=json.load(open(p,encoding='utf-8'))\\nkeys=set()\\nfor f in d['fields']: keys|=set(f.keys())\\nprint('ALL KEYS:',keys)\\nprint('---phone/telephone fields full---')\\nfor f in d['fields']:\\n n=f['name'].lower()\\n if 'phone' in n or 'telephone' in n:\\n print(json.dumps(f,ensure_ascii=False))\\n\\\"\",\"description\":\"Inspect field keys and phone fields\"},\"caller\":{\"type\":\"direct\"}}],\"stop_reason\":\"tool_use\",\"stop_sequence\":null,\"stop_details\":null,\"usage\":{\"input_tokens\":2,\"cache_creation_input_tokens\":399,\"cache_read_input_tokens\":52844,\"output_tokens\":432,\"server_tool_use\":{\"web_search_requests\":0,\"web_fetch_requests\":0},\"service_tier\":\"standard\",\"cache_creation\":{\"ephemeral_1h_input_tokens\":399,\"ephemeral_5m_input_tokens\":0},\"inference_geo\":\"not_available\",\"iterations\":[{\"input_tokens\":2,\"output_tokens\":432,\"cache_read_input_tokens\":52844,\"cache_creation_input_tokens\":399,\"cache_creation\":{\"ephemeral_5m_input_tokens\":0,\"ephemeral_1h_input_tokens\":399},\"type\":\"message\"}],\"speed\":\"standard\"},\"diagnostics\":null},\"requestId\":\"req_011Cc7QBF5XBnnP7cqBpGRVX\",\"attributionMcpServer\":\"claude.ai Instafill\",\"attributionMcpTool\":\"get_filled_form_data\",\"type\":\"assistant\",\"uuid\":\"cfc994da-d3d6-47d6-a38f-9467969cec71\",\"timestamp\":\"2026-06-16T18:19:37.829Z\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"C:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"parentUuid\":\"cfc994da-d3d6-47d6-a38f-9467969cec71\",\"isSidechain\":false,\"promptId\":\"ee4d1f2e-e39b-411a-8c3b-307951e229ea\",\"type\":\"user\",\"message\":{\"role\":\"user\",\"content\":[{\"tool_use_id\":\"toolu_015eVKXksRuDGsMzD9uYn7Gr\",\"type\":\"tool_result\",\"content\":\"ALL KEYS: {'group', 'description', 'page_num', 'name'}\\r\\n---phone/telephone fields full---\\r\\n{\\\"name\\\": \\\"Patient Telephone (Area Code)\\\", \\\"description\\\": \\\"Enter the area code for the patient's telephone number.\\\", \\\"group\\\": \\\"Patient Address & Phone\\\", \\\"page_num\\\": 0}\\r\\n{\\\"name\\\": \\\"Patient Telephone Number\\\", \\\"description\\\": \\\"Enter the patient's telephone number.\\\", \\\"group\\\": \\\"Patient Address & Phone\\\", \\\"page_num\\\": 0}\\r\\n{\\\"name\\\": \\\"Insured Phone Area Code\\\", \\\"description\\\": \\\"Enter the area code for the insured�s telephone number.\\\", \\\"group\\\": \\\"Insured Address & Phone\\\", \\\"page_num\\\": 0}\\r\\n{\\\"name\\\": \\\"Insured Phone Number\\\", \\\"description\\\": \\\"Enter the insured�s telephone number excluding the area code.\\\", \\\"group\\\": \\\"Insured Address & Phone\\\", \\\"page_num\\\": 0}\\r\\n{\\\"name\\\": \\\"Billing Provider Phone Area Code\\\", \\\"description\\\": \\\"Enter the area code portion of the billing provider�s phone number.\\\", \\\"group\\\": \\\"Billing Provider Info & Phone (Item 33)\\\", \\\"page_num\\\": 0}\\r\\n{\\\"name\\\": \\\"Billing Provider Phone Number\\\", \\\"description\\\": \\\"Enter the remaining digits of the billing provider�s phone number.\\\", \\\"group\\\": \\\"Billing Provider Info & Phone (Item 33)\\\", \\\"page_num\\\": 0}\",\"is_error\":false}]},\"uuid\":\"9b8b9ec2-2f5a-435d-bd9c-f517b8e5c25c\",\"timestamp\":\"2026-06-16T18:19:40.246Z\",\"toolUseResult\":{\"stdout\":\"ALL KEYS: {'group', 'description', 'page_num', 'name'}\\r\\n---phone/telephone fields full---\\r\\n{\\\"name\\\": \\\"Patient Telephone (Area Code)\\\", \\\"description\\\": \\\"Enter the area code for the patient's telephone number.\\\", \\\"group\\\": \\\"Patient Address & Phone\\\", \\\"page_num\\\": 0}\\r\\n{\\\"name\\\": \\\"Patient Telephone Number\\\", \\\"description\\\": \\\"Enter the patient's telephone number.\\\", \\\"group\\\": \\\"Patient Address & Phone\\\", \\\"page_num\\\": 0}\\r\\n{\\\"name\\\": \\\"Insured Phone Area Code\\\", \\\"description\\\": \\\"Enter the area code for the insured�s telephone number.\\\", \\\"group\\\": \\\"Insured Address & Phone\\\", \\\"page_num\\\": 0}\\r\\n{\\\"name\\\": \\\"Insured Phone Number\\\", \\\"description\\\": \\\"Enter the insured�s telephone number excluding the area code.\\\", \\\"group\\\": \\\"Insured Address & Phone\\\", \\\"page_num\\\": 0}\\r\\n{\\\"name\\\": \\\"Billing Provider Phone Area Code\\\", \\\"description\\\": \\\"Enter the area code portion of the billing provider�s phone number.\\\", \\\"group\\\": \\\"Billing Provider Info & Phone (Item 33)\\\", \\\"page_num\\\": 0}\\r\\n{\\\"name\\\": \\\"Billing Provider Phone Number\\\", \\\"description\\\": \\\"Enter the remaining digits of the billing provider�s phone number.\\\", \\\"group\\\": \\\"Billing Provider Info & Phone (Item 33)\\\", \\\"page_num\\\": 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Let me re-check status, then re-pull the data.\"}],\"stop_reason\":\"tool_use\",\"stop_sequence\":null,\"stop_details\":null,\"usage\":{\"input_tokens\":2,\"cache_creation_input_tokens\":867,\"cache_read_input_tokens\":53243,\"output_tokens\":537,\"server_tool_use\":{\"web_search_requests\":0,\"web_fetch_requests\":0},\"service_tier\":\"standard\",\"cache_creation\":{\"ephemeral_1h_input_tokens\":867,\"ephemeral_5m_input_tokens\":0},\"inference_geo\":\"not_available\",\"iterations\":[{\"input_tokens\":2,\"output_tokens\":537,\"cache_read_input_tokens\":53243,\"cache_creation_input_tokens\":867,\"cache_creation\":{\"ephemeral_5m_input_tokens\":0,\"ephemeral_1h_input_tokens\":867},\"type\":\"message\"}],\"speed\":\"standard\"},\"diagnostics\":null},\"requestId\":\"req_011Cc7QBsKrFQ46ezvPxdEpf\",\"attributionMcpServer\":\"claude.ai 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Full output saved to: C:\\\\Users\\\\smirn\\\\.claude\\\\projects\\\\c--Users-smirn-OneDrive-Documents-GitHub-botmakers-projects-copilot-us-instafill-ai\\\\986638d6-b238-4e02-83a0-449ec3df5830\\\\tool-results\\\\toolu_01RkkMAddd6RiEjQwngqSQm5.txt\\n\\nPreview (first 2KB):\\n{\\\"session_id\\\":\\\"6a31926c7577317a2d1300be\\\",\\\"form_id\\\":\\\"6a3185a67577317a2d1300ae\\\",\\\"fields\\\":[{\\\"name\\\":\\\"PICA Code (Left)\\\",\\\"description\\\":\\\"Enter the Payer/Carrier Code (PICA) shown on your insurance card or provided by your plan for this claim.\\\",\\\"group\\\":\\\"Payer/Carrier Codes (PICA)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"PICA1 (top left)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"PICA2 (top left)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"PICA3 (top left)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"PICA Code (Right)\\\",\\\"description\\\":\\\"Enter the Payer/Carrier Code (PICA) for the carrier receiving this claim, if a separate PICA code is 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Number\\\",\\\"descript\\n...\\n\"}]},\"uuid\":\"9c62f510-a499-4bb8-b3c9-d25e457b3197\",\"timestamp\":\"2026-06-16T18:20:06.061Z\",\"toolUseResult\":\"{\\\"session_id\\\":\\\"6a31926c7577317a2d1300be\\\",\\\"form_id\\\":\\\"6a3185a67577317a2d1300ae\\\",\\\"fields\\\":[{\\\"name\\\":\\\"PICA Code (Left)\\\",\\\"description\\\":\\\"Enter the Payer/Carrier Code (PICA) shown on your insurance card or provided by your plan for this claim.\\\",\\\"group\\\":\\\"Payer/Carrier Codes (PICA)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"PICA1 (top left)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"PICA2 (top left)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"PICA3 (top left)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"PICA Code (Right)\\\",\\\"description\\\":\\\"Enter the Payer/Carrier Code (PICA) for the carrier receiving this claim, if a separate PICA code is required.\\\",\\\"group\\\":\\\"Payer/Carrier Codes (PICA)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"PICA1 (top right)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"PICA2 (top right)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"PICA3 (top right)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Medicare\\\",\\\"description\\\":\\\"Check this box if the patient’s coverage for this claim is through Medicare.\\\",\\\"group\\\":\\\"Insurance Program Selection\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Medicaid\\\",\\\"description\\\":\\\"Check this box if the patient’s coverage for this claim is through Medicaid.\\\",\\\"group\\\":\\\"Insurance Program Selection\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"TRICARE\\\",\\\"description\\\":\\\"Check this box if the patient’s coverage for this claim is through TRICARE.\\\",\\\"group\\\":\\\"Insurance Program Selection\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"CHAMPVA\\\",\\\"description\\\":\\\"Check this box if the patient’s coverage for this claim is through CHAMPVA.\\\",\\\"group\\\":\\\"Insurance Program Selection\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Group Health Plan\\\",\\\"description\\\":\\\"Check this box if the patient’s coverage for this claim is through a Group Health Plan.\\\",\\\"group\\\":\\\"Insurance Program Selection\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"FECA / Black Lung\\\",\\\"description\\\":\\\"Check this box if the claim is covered under FECA or the Black Lung program.\\\",\\\"group\\\":\\\"Insurance Program Selection\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other\\\",\\\"description\\\":\\\"Check this box if the patient’s coverage for this claim is through another program not listed and enter the program ID number.\\\",\\\"group\\\":\\\"Insurance Program Selection\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured ID Number\\\",\\\"description\\\":\\\"Enter the insured person’s identification number exactly as shown on the insurance card. Fill only if 'Medicare', 'Medicaid', 'TRICARE', 'CHAMPVA', 'Group Health Plan', 'FECA / Black Lung', 'Other' is 'Yes' (any).\\\",\\\"group\\\":\\\"Patient & Insured Basic Info\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Patient Name\\\",\\\"description\\\":\\\"Enter the patient’s full name (last name, first name, and middle initial).\\\",\\\"group\\\":\\\"Patient & Insured Basic Info\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Patient Birth Month\\\",\\\"description\\\":\\\"Enter the month of the patient’s date of birth.\\\",\\\"group\\\":\\\"Patient & Insured Basic Info\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Patient Birth Day\\\",\\\"description\\\":\\\"Enter the day of the month of the patient’s date of birth.\\\",\\\"group\\\":\\\"Patient & Insured Basic Info\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Patient Birth Year\\\",\\\"description\\\":\\\"Enter the year of the patient’s date of birth.\\\",\\\"group\\\":\\\"Patient & Insured Basic Info\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Sex: Male\\\",\\\"description\\\":\\\"Check this box if the patient is male.\\\",\\\"group\\\":\\\"Patient & Insured Basic Info\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Sex: Female\\\",\\\"description\\\":\\\"Check this box if the patient is female.\\\",\\\"group\\\":\\\"Patient & Insured Basic Info\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured Name\\\",\\\"description\\\":\\\"Enter the insured person’s full name (last name, first name, and middle initial).\\\",\\\"group\\\":\\\"Patient & Insured Basic Info\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Patient Street Address\\\",\\\"description\\\":\\\"Enter the patient's street address (house/building number and street name).\\\",\\\"group\\\":\\\"Patient Address & Phone\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Patient City\\\",\\\"description\\\":\\\"Enter the city where the patient lives.\\\",\\\"group\\\":\\\"Patient Address & Phone\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Patient State\\\",\\\"description\\\":\\\"Enter the state where the patient lives.\\\",\\\"group\\\":\\\"Patient Address & Phone\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Patient ZIP Code\\\",\\\"description\\\":\\\"Enter the patient's ZIP or postal code.\\\",\\\"group\\\":\\\"Patient Address & Phone\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Patient Telephone (Area Code)\\\",\\\"description\\\":\\\"Enter the area code for the patient's telephone number.\\\",\\\"group\\\":\\\"Patient Address & Phone\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Patient Telephone Number\\\",\\\"description\\\":\\\"Enter the patient's telephone number.\\\",\\\"group\\\":\\\"Patient Address & Phone\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Self\\\",\\\"description\\\":\\\"Check this box if the patient is the insured person (the policyholder).\\\",\\\"group\\\":\\\"Patient Relationship to Insured\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Spouse\\\",\\\"description\\\":\\\"Check this box if the patient is the insured person’s spouse.\\\",\\\"group\\\":\\\"Patient Relationship to Insured\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Child\\\",\\\"description\\\":\\\"Check this box if the patient is the insured person’s child (dependent).\\\",\\\"group\\\":\\\"Patient Relationship to Insured\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other\\\",\\\"description\\\":\\\"Check this box if the patient’s relationship to the insured is not self, spouse, or child.\\\",\\\"group\\\":\\\"Patient Relationship to Insured\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured Street Address\\\",\\\"description\\\":\\\"Enter the insured’s street address (number and street name).\\\",\\\"group\\\":\\\"Insured Address & Phone\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured City\\\",\\\"description\\\":\\\"Enter the city for the insured’s mailing address.\\\",\\\"group\\\":\\\"Insured Address & Phone\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured State\\\",\\\"description\\\":\\\"Enter the state for the insured’s mailing address.\\\",\\\"group\\\":\\\"Insured Address & Phone\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured ZIP Code\\\",\\\"description\\\":\\\"Enter the ZIP code for the insured’s mailing address.\\\",\\\"group\\\":\\\"Insured Address & Phone\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured Phone Area Code\\\",\\\"description\\\":\\\"Enter the area code for the insured’s telephone number.\\\",\\\"group\\\":\\\"Insured Address & Phone\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured Phone Number\\\",\\\"description\\\":\\\"Enter the insured’s telephone number excluding the area code.\\\",\\\"group\\\":\\\"Insured Address & Phone\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"NUCC Use (Item 8)\\\",\\\"description\\\":\\\"Enter any code or information provided by NUCC for Item 8, if applicable; otherwise leave blank.\\\",\\\"group\\\":\\\"Reserved for NUCC Use (Item 8)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other Insured Name\\\",\\\"description\\\":\\\"Enter the other insured person’s full name (last name, first name, middle initial) as it appears on their insurance card. Fill only if 'Yes' is 'Yes'.\\\",\\\"group\\\":\\\"Other Insured Information\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other Insured Policy/Group Number\\\",\\\"description\\\":\\\"Enter the policy number or group number for the other insured person’s health plan. Fill only if 'Yes' is 'Yes'.\\\",\\\"group\\\":\\\"Other Insured Information\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Reserved for NUCC Use (9b)\\\",\\\"description\\\":\\\"Enter the value requested for this reserved NUCC field, if instructed to do so by the payer. Fill only if 'Yes' is 'Yes'.\\\",\\\"group\\\":\\\"Other Insured Information\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Reserved for NUCC Use (9c)\\\",\\\"description\\\":\\\"Enter the value requested for this reserved NUCC field, if instructed to do so by the payer. Fill only if 'Yes' is 'Yes'.\\\",\\\"group\\\":\\\"Other Insured Information\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other Insurance Plan/Program Name\\\",\\\"description\\\":\\\"Enter the name of the other insured person’s insurance plan or program. Fill only if 'Yes' is 'Yes'.\\\",\\\"group\\\":\\\"Other Insured Information\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Employment? (Current or Previous) — Yes\\\",\\\"description\\\":\\\"Check this box if the patient’s condition is related to current or previous employment.\\\",\\\"group\\\":\\\"Patient Condition Related To (Employment/Accidents)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Employment? (Current or Previous) — No\\\",\\\"description\\\":\\\"Check this box if the patient’s condition is not related to current or previous employment.\\\",\\\"group\\\":\\\"Patient Condition Related To (Employment/Accidents)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Auto Accident? — Yes\\\",\\\"description\\\":\\\"Check this box if the patient’s condition is related to an automobile accident.\\\",\\\"group\\\":\\\"Patient Condition Related To (Employment/Accidents)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Auto Accident? — No\\\",\\\"description\\\":\\\"Check this box if the patient’s condition is not related to an automobile accident.\\\",\\\"group\\\":\\\"Patient Condition Related To (Employment/Accidents)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Auto Accident Location (State)\\\",\\\"description\\\":\\\"Enter the U.S. state where the auto accident occurred, if the patient’s condition is related to an auto accident. Fill only if 'Auto Accident? — Yes' is 'Yes'.\\\",\\\"group\\\":\\\"Patient Condition Related To (Employment/Accidents)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other Accident? — Yes\\\",\\\"description\\\":\\\"Check this box if the patient’s condition is related to an accident other than an auto accident.\\\",\\\"group\\\":\\\"Patient Condition Related To (Employment/Accidents)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other Accident? — No\\\",\\\"description\\\":\\\"Check this box if the patient’s condition is not related to any accident other than an auto accident.\\\",\\\"group\\\":\\\"Patient Condition Related To (Employment/Accidents)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Claim Codes (10d)\\\",\\\"description\\\":\\\"Enter any applicable claim codes for this claim as designated by the NUCC.\\\",\\\"group\\\":\\\"Claim Codes (10d)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured Policy Group or FECA Number\\\",\\\"description\\\":\\\"Enter the insured person’s policy group number or FECA number as shown on the insurance information.\\\",\\\"group\\\":\\\"Insured Policy & Demographics\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured Date of Birth (Month)\\\",\\\"description\\\":\\\"Enter the month of the insured person’s date of birth.\\\",\\\"group\\\":\\\"Insured Policy & Demographics\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured Date of Birth (Day)\\\",\\\"description\\\":\\\"Enter the day of the month of the insured person’s date of birth.\\\",\\\"group\\\":\\\"Insured Policy & Demographics\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured Date of Birth (Year)\\\",\\\"description\\\":\\\"Enter the year of the insured person’s date of birth.\\\",\\\"group\\\":\\\"Insured Policy & Demographics\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Sex - Male (M)\\\",\\\"description\\\":\\\"Check this box if the insured person is male.\\\",\\\"group\\\":\\\"Insured Policy & Demographics\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Sex - Female (F)\\\",\\\"description\\\":\\\"Check this box if the insured person is female.\\\",\\\"group\\\":\\\"Insured Policy & Demographics\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other Claim ID Qualifier\\\",\\\"description\\\":\\\"Enter the qualifier code that identifies the type/source of the other claim ID.\\\",\\\"group\\\":\\\"Other Claim ID & Plan Name\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other Claim ID\\\",\\\"description\\\":\\\"Enter the other claim identification number associated with the patient’s coverage.\\\",\\\"group\\\":\\\"Other Claim ID & Plan Name\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other Insurance Plan Name\\\",\\\"description\\\":\\\"Enter the name of the other insurance plan or program related to the other claim.\\\",\\\"group\\\":\\\"Other Claim ID & Plan Name\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Yes\\\",\\\"description\\\":\\\"Check this box if the patient is covered by another health benefit plan in addition to the plan listed on this claim.\\\",\\\"group\\\":\\\"Another Health Benefit Plan (11d)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"No\\\",\\\"description\\\":\\\"Check this box if the patient is not covered by any other health benefit plan besides the plan listed on this claim.\\\",\\\"group\\\":\\\"Another Health Benefit Plan (11d)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Patient/Authorized Person Signature\\\",\\\"description\\\":\\\"Enter the signature of the patient or the authorized person who is signing to authorize release of information and payment of benefits.\\\",\\\"group\\\":\\\"Patient/Insured Signatures & Dates\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Signature Date (Patient/Authorized Person)\\\",\\\"description\\\":\\\"Enter the date the patient or authorized person signed the form.\\\",\\\"group\\\":\\\"Patient/Insured Signatures & Dates\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Insured/Authorized Person Signature\\\",\\\"description\\\":\\\"Enter the signature of the insured or authorized person authorizing payment of medical benefits to the provider or supplier.\\\",\\\"group\\\":\\\"Patient/Insured Signatures & Dates\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Current Illness/Injury Date - Month\\\",\\\"description\\\":\\\"Enter the month of the date of current illness, injury, or pregnancy (LMP).\\\",\\\"group\\\":\\\"Illness/Injury/Other Dates (Items 14-15)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Current Illness/Injury Date - Day\\\",\\\"description\\\":\\\"Enter the day of the date of current illness, injury, or pregnancy (LMP).\\\",\\\"group\\\":\\\"Illness/Injury/Other Dates (Items 14-15)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Current Illness/Injury Date - Year\\\",\\\"description\\\":\\\"Enter the year of the date of current illness, injury, or pregnancy (LMP).\\\",\\\"group\\\":\\\"Illness/Injury/Other Dates (Items 14-15)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Current Illness/Injury Date Qualifier\\\",\\\"description\\\":\\\"Enter the qualifier code that indicates what the date of current illness, injury, or pregnancy represents.\\\",\\\"group\\\":\\\"Illness/Injury/Other Dates (Items 14-15)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other Date Qualifier\\\",\\\"description\\\":\\\"Enter the qualifier code that indicates what the other date represents.\\\",\\\"group\\\":\\\"Illness/Injury/Other Dates (Items 14-15)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other Date - Month\\\",\\\"description\\\":\\\"Enter the month for the other date indicated by the qualifier.\\\",\\\"group\\\":\\\"Illness/Injury/Other Dates (Items 14-15)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other Date - Day\\\",\\\"description\\\":\\\"Enter the day for the other date indicated by the qualifier.\\\",\\\"group\\\":\\\"Illness/Injury/Other Dates (Items 14-15)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Other Date - Year\\\",\\\"description\\\":\\\"Enter the year for the other date indicated by the qualifier.\\\",\\\"group\\\":\\\"Illness/Injury/Other Dates (Items 14-15)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Unable to Work From (Month)\\\",\\\"description\\\":\\\"Enter the month when the patient first became unable to work in their current occupation.\\\",\\\"group\\\":\\\"Unable to Work Dates (Item 16)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Unable to Work From (Day)\\\",\\\"description\\\":\\\"Enter the day of the month when the patient first became unable to work in their current occupation.\\\",\\\"group\\\":\\\"Unable to Work Dates (Item 16)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Unable to Work From (Year)\\\",\\\"description\\\":\\\"Enter the year when the patient first became unable to work in their current occupation.\\\",\\\"group\\\":\\\"Unable to Work Dates (Item 16)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Unable to Work To (Month)\\\",\\\"description\\\":\\\"Enter the month when the patient returned to work (or the end month of the period they were unable to work).\\\",\\\"group\\\":\\\"Unable to Work Dates (Item 16)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Unable to Work To (Day)\\\",\\\"description\\\":\\\"Enter the day of the month when the patient returned to work (or the end day of the period they were unable to work).\\\",\\\"group\\\":\\\"Unable to Work Dates (Item 16)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Unable to Work To (Year)\\\",\\\"description\\\":\\\"Enter the year when the patient returned to work (or the end year of the period they were unable to work).\\\",\\\"group\\\":\\\"Unable to Work Dates (Item 16)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Referring provider last name\\\",\\\"description\\\":\\\"Enter the referring provider’s last name.\\\",\\\"group\\\":\\\"Referring Provider Information (Item 17)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Referring provider first name\\\",\\\"description\\\":\\\"Enter the referring provider’s first name (and middle initial if applicable).\\\",\\\"group\\\":\\\"Referring Provider Information (Item 17)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Referring provider ID qualifier (17a)\\\",\\\"description\\\":\\\"Enter the qualifier that identifies the type of non-NPI referring provider ID reported in Item 17a.\\\",\\\"group\\\":\\\"Referring Provider Information (Item 17)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Referring provider ID number (17a)\\\",\\\"description\\\":\\\"Enter the referring provider’s non-NPI identification number corresponding to the qualifier in Item 17a.\\\",\\\"group\\\":\\\"Referring Provider Information (Item 17)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Referring provider NPI (17b)\\\",\\\"description\\\":\\\"Enter the referring provider’s National Provider Identifier (NPI).\\\",\\\"group\\\":\\\"Referring Provider Information (Item 17)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Hospitalization From - Month\\\",\\\"description\\\":\\\"Enter the month the hospitalization began (FROM date).\\\",\\\"group\\\":\\\"Hospitalization Dates (Item 18)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Hospitalization From - Day\\\",\\\"description\\\":\\\"Enter the day of the month the hospitalization began (FROM date).\\\",\\\"group\\\":\\\"Hospitalization Dates (Item 18)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Hospitalization From - Year\\\",\\\"description\\\":\\\"Enter the year the hospitalization began (FROM date).\\\",\\\"group\\\":\\\"Hospitalization Dates (Item 18)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Hospitalization To - Month\\\",\\\"description\\\":\\\"Enter the month the hospitalization ended (TO date). Fill only if 'Hospitalization From - Day' is 'Yes'.\\\",\\\"group\\\":\\\"Hospitalization Dates (Item 18)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Hospitalization To - Day\\\",\\\"description\\\":\\\"Enter the day of the month the hospitalization ended (TO date).\\\",\\\"group\\\":\\\"Hospitalization Dates (Item 18)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Hospitalization To - Year\\\",\\\"description\\\":\\\"Enter the year the hospitalization ended (TO date).\\\",\\\"group\\\":\\\"Hospitalization Dates (Item 18)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Additional Claim Information\\\",\\\"description\\\":\\\"Enter any additional claim information or remarks designated by NUCC that apply to this claim.\\\",\\\"group\\\":\\\"Additional Claim Info & Outside Lab (Items 19-20)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Outside Lab: Yes\\\",\\\"description\\\":\\\"Check this box if the lab work for this claim was performed by an outside (non-office) laboratory.\\\",\\\"group\\\":\\\"Additional Claim Info & Outside Lab (Items 19-20)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Outside Lab: No\\\",\\\"description\\\":\\\"Check this box if the lab work for this claim was not performed by an outside laboratory.\\\",\\\"group\\\":\\\"Additional Claim Info & Outside Lab (Items 19-20)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Outside Lab Indicator\\\",\\\"description\\\":\\\"Indicate whether the services were performed by an outside laboratory (e.g., enter Yes or No).\\\",\\\"group\\\":\\\"Additional Claim Info & Outside Lab (Items 19-20)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Outside Lab Charges\\\",\\\"description\\\":\\\"Enter the total charges amount for services performed by an outside laboratory.\\\",\\\"group\\\":\\\"Additional Claim Info & Outside Lab (Items 19-20)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"ICD Indicator\\\",\\\"description\\\":\\\"Enter the ICD code set indicator that applies to the diagnosis codes listed (as required by the form).\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Code A\\\",\\\"description\\\":\\\"Enter the primary diagnosis code (A) describing the patient’s illness or injury.\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Code B\\\",\\\"description\\\":\\\"Enter diagnosis code B describing the patient’s illness or injury.\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Code C\\\",\\\"description\\\":\\\"Enter diagnosis code C describing the patient’s illness or injury.\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Code D\\\",\\\"description\\\":\\\"Enter diagnosis code D describing the patient’s illness or injury.\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Code E\\\",\\\"description\\\":\\\"Enter diagnosis code E describing the patient’s illness or injury.\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Code F\\\",\\\"description\\\":\\\"Enter diagnosis code F describing the patient’s illness or injury.\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Code G\\\",\\\"description\\\":\\\"Enter diagnosis code G describing the patient’s illness or injury.\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Code H\\\",\\\"description\\\":\\\"Enter diagnosis code H describing the patient’s illness or injury.\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Code I\\\",\\\"description\\\":\\\"Enter diagnosis code I describing the patient’s illness or injury.\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Code J\\\",\\\"description\\\":\\\"Enter diagnosis code J describing the patient’s illness or injury.\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Code K\\\",\\\"description\\\":\\\"Enter diagnosis code K describing the patient’s illness or injury.\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Code L\\\",\\\"description\\\":\\\"Enter diagnosis code L describing the patient’s illness or injury.\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Code M\\\",\\\"description\\\":\\\"Enter an additional diagnosis code (M) describing the patient’s illness or injury, if applicable.\\\",\\\"group\\\":\\\"Diagnosis Information (Item 21)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Resubmission Code\\\",\\\"description\\\":\\\"Enter the code that indicates this claim is a resubmission or corrected/replacement claim, if applicable.\\\",\\\"group\\\":\\\"Resubmission & Original Reference (Item 22)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Original Reference Number\\\",\\\"description\\\":\\\"Enter the reference number or identifier for the original claim being resubmitted or corrected.\\\",\\\"group\\\":\\\"Resubmission & Original Reference (Item 22)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Prior Authorization Number\\\",\\\"description\\\":\\\"Enter the prior authorization number issued for the services being claimed (Item 23).\\\",\\\"group\\\":\\\"Prior Authorization Number (Item 23)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service From Month\\\",\\\"description\\\":\\\"Enter the month of the start date of service for this service line.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service From Day\\\",\\\"description\\\":\\\"Enter the day of the start date of service for this service line.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service From Year\\\",\\\"description\\\":\\\"Enter the year of the start date of service for this service line.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service To Month\\\",\\\"description\\\":\\\"Enter the month of the end date of service for this service line, if applicable.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service To Day\\\",\\\"description\\\":\\\"Enter the day of the end date of service for this service line, if applicable.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service To Year\\\",\\\"description\\\":\\\"Enter the year of the end date of service for this service line, if applicable.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Place of Service\\\",\\\"description\\\":\\\"Enter the place of service code that indicates where the service was provided.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Emergency Indicator\\\",\\\"description\\\":\\\"Enter the emergency indicator value for this service line, if required.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Procedure Code (CPT/HCPCS)\\\",\\\"description\\\":\\\"Enter the CPT or HCPCS procedure code for the service provided.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Modifier 1\\\",\\\"description\\\":\\\"Enter the first procedure modifier, if applicable.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Modifier 2\\\",\\\"description\\\":\\\"Enter the second procedure modifier, if applicable.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Modifier 3\\\",\\\"description\\\":\\\"Enter the third procedure modifier, if applicable.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Modifier 4\\\",\\\"description\\\":\\\"Enter the fourth procedure modifier, if applicable.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Pointer\\\",\\\"description\\\":\\\"Enter the diagnosis code reference(s) (pointer) that apply to this procedure.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Line Item Charges\\\",\\\"description\\\":\\\"Enter the total charge amount for this service line.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Days or Units\\\",\\\"description\\\":\\\"Enter the number of days or units billed for this service line.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"EPSDT/Family Plan\\\",\\\"description\\\":\\\"Enter the EPSDT or family planning indicator/code, if applicable.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Rendering Provider ID Qualifier\\\",\\\"description\\\":\\\"Enter the qualifier that identifies the type of non-NPI rendering provider identifier being reported.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Rendering Provider NPI\\\",\\\"description\\\":\\\"Enter the rendering provider’s National Provider Identifier (NPI) for this service line.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Row 1 — 24J Rendering Provider ID #\\\",\\\"description\\\":\\\"Enter the rendering provider's identifier for Row 1 (24J), for example the provider's NPI or other assigned ID.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Rendering Provider Other ID\\\",\\\"description\\\":\\\"Enter the rendering provider’s non-NPI identifier for this service line, if applicable.\\\",\\\"group\\\":\\\"First Service Line (Item 24 - Row 1)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Date From (Month)\\\",\\\"description\\\":\\\"Enter the month portion of the beginning date of service for the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Date From (Day)\\\",\\\"description\\\":\\\"Enter the day portion of the beginning date of service for the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Date From (Year)\\\",\\\"description\\\":\\\"Enter the year portion of the beginning date of service for the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Date To (Month)\\\",\\\"description\\\":\\\"Enter the month portion of the ending date of service for the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Date To (Day)\\\",\\\"description\\\":\\\"Enter the day portion of the ending date of service for the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Date To (Year)\\\",\\\"description\\\":\\\"Enter the year portion of the ending date of service for the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Place of Service Code\\\",\\\"description\\\":\\\"Enter the place of service code that identifies where the services were provided for the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Emergency Indicator (EMG)\\\",\\\"description\\\":\\\"Enter the emergency indicator value for the second service line, if applicable.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Procedure Code (CPT/HCPCS)\\\",\\\"description\\\":\\\"Enter the CPT or HCPCS procedure/service code for the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Procedure Modifier 1\\\",\\\"description\\\":\\\"Enter the first procedure modifier associated with the procedure code for the second service line, if any.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Procedure Modifier 2\\\",\\\"description\\\":\\\"Enter the second procedure modifier associated with the procedure code for the second service line, if any.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Procedure Modifier 3\\\",\\\"description\\\":\\\"Enter the third procedure modifier associated with the procedure code for the second service line, if any.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Procedure Modifier 4\\\",\\\"description\\\":\\\"Enter the fourth procedure modifier associated with the procedure code for the second service line, if any.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Pointer\\\",\\\"description\\\":\\\"Enter the diagnosis pointer(s) that link this service to the relevant diagnosis code(s) for the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Line Item Charge Amount\\\",\\\"description\\\":\\\"Enter the total charge amount being billed for the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Days or Units\\\",\\\"description\\\":\\\"Enter the number of days or units for the billed service on the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"EPSDT Indicator\\\",\\\"description\\\":\\\"Enter the EPSDT indicator value for the second service line, if applicable.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Family Planning Indicator\\\",\\\"description\\\":\\\"Enter the family planning indicator value for the second service line, if applicable.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Rendering Provider ID Qualifier\\\",\\\"description\\\":\\\"Enter the qualifier that identifies the type of rendering provider identifier reported for the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Rendering Provider NPI\\\",\\\"description\\\":\\\"Enter the rendering provider's NPI for the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Rendering Provider Other ID\\\",\\\"description\\\":\\\"Enter the rendering provider's other identifier (non-NPI), if applicable, for the second service line.\\\",\\\"group\\\":\\\"Second Service Line (Item 24 - Row 2)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"From Date of Service - Month\\\",\\\"description\\\":\\\"Enter the month of the start (FROM) date of service for this third service line.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"From Date of Service - Day\\\",\\\"description\\\":\\\"Enter the day of the start (FROM) date of service for this third service line.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"From Date of Service - Year\\\",\\\"description\\\":\\\"Enter the year of the start (FROM) date of service for this third service line.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"To Date of Service - Month\\\",\\\"description\\\":\\\"Enter the month of the end (TO) date of service for this third service line, if different from the from date.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"To Date of Service - Day\\\",\\\"description\\\":\\\"Enter the day of the end (TO) date of service for this third service line, if different from the from date.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"To Date of Service - Year\\\",\\\"description\\\":\\\"Enter the year of the end (TO) date of service for this third service line, if different from the from date.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Place of Service\\\",\\\"description\\\":\\\"Enter the place of service code for where the service was performed on this third service line.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Emergency Indicator\\\",\\\"description\\\":\\\"Enter the emergency indicator for this third service line, if applicable.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Procedure/Service Code (CPT/HCPCS)\\\",\\\"description\\\":\\\"Enter the CPT/HCPCS procedure or service code billed on this third service line.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Modifier 1\\\",\\\"description\\\":\\\"Enter the first procedure modifier for the CPT/HCPCS code on this third service line, if applicable.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Modifier 2\\\",\\\"description\\\":\\\"Enter the second procedure modifier for the CPT/HCPCS code on this third service line, if applicable.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Modifier 3\\\",\\\"description\\\":\\\"Enter the third procedure modifier for the CPT/HCPCS code on this third service line, if applicable.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Modifier 4\\\",\\\"description\\\":\\\"Enter the fourth procedure modifier for the CPT/HCPCS code on this third service line, if applicable.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Pointer\\\",\\\"description\\\":\\\"Enter the diagnosis code reference letter(s) (from Item 21) that apply to this third service line.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Charges - Dollars\\\",\\\"description\\\":\\\"Enter the dollar amount charged for this third service line.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Charges - Cents\\\",\\\"description\\\":\\\"Enter the cents portion of the amount charged for this third service line.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Days or Units\\\",\\\"description\\\":\\\"Enter the number of days or units for the service billed on this third service line.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"EPSDT/Family Plan\\\",\\\"description\\\":\\\"Enter the EPSDT/Family Plan indicator for this third service line, if applicable.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Rendering Provider ID Qualifier\\\",\\\"description\\\":\\\"Enter the qualifier that identifies the type of non-NPI rendering provider identifier reported for this third service line, if applicable.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Rendering Provider NPI\\\",\\\"description\\\":\\\"Enter the rendering provider's NPI for this third service line.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Rendering Provider Other ID\\\",\\\"description\\\":\\\"Enter the rendering provider's non-NPI identifier for this third service line, if applicable.\\\",\\\"group\\\":\\\"Third Service Line (Item 24 - Row 3)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 From Date (MM)\\\",\\\"description\\\":\\\"Enter the month of the start date for the service period on this service line.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 From Date (DD)\\\",\\\"description\\\":\\\"Enter the day of the start date for the service period on this service line.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 From Date (YY)\\\",\\\"description\\\":\\\"Enter the two-digit year of the start date for the service period on this service line.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 To Date (MM)\\\",\\\"description\\\":\\\"Enter the month of the end date for the service period on this service line.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 To Date (DD)\\\",\\\"description\\\":\\\"Enter the day of the end date for the service period on this service line.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 To Date (YY)\\\",\\\"description\\\":\\\"Enter the two-digit year of the end date for the service period on this service line.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Place of Service\\\",\\\"description\\\":\\\"Enter the place of service code that describes where the service was provided for this service line.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Emergency Indicator\\\",\\\"description\\\":\\\"Enter the emergency indicator value for this service line, if applicable.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Procedure Code (CPT/HCPCS)\\\",\\\"description\\\":\\\"Enter the CPT/HCPCS procedure code for the service or item billed on this service line.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Modifier 1\\\",\\\"description\\\":\\\"Enter the first procedure modifier associated with the billed procedure code on this service line, if any.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Modifier 2\\\",\\\"description\\\":\\\"Enter the second procedure modifier associated with the billed procedure code on this service line, if any.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Modifier 3\\\",\\\"description\\\":\\\"Enter the third procedure modifier associated with the billed procedure code on this service line, if any.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Modifier 4\\\",\\\"description\\\":\\\"Enter the fourth procedure modifier associated with the billed procedure code on this service line, if any.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Diagnosis Pointer\\\",\\\"description\\\":\\\"Enter the diagnosis pointer(s) that link this service line to the diagnosis code(s) listed in the diagnosis section.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Charges\\\",\\\"description\\\":\\\"Enter the total charge amount being billed for this service line.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Days or Units\\\",\\\"description\\\":\\\"Enter the number of days or units for the service billed on this service line.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 EPSDT/Family Plan\\\",\\\"description\\\":\\\"Enter the EPSDT or family planning indicator for this service line, if applicable.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Provider ID Qualifier\\\",\\\"description\\\":\\\"Enter the qualifier that identifies the type of provider ID reported for this service line, if applicable.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Rendering Provider ID (Non-NPI)\\\",\\\"description\\\":\\\"Enter the rendering provider's non-NPI identifier for this service line, if required by the payer.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Rendering Provider NPI\\\",\\\"description\\\":\\\"Enter the rendering provider's National Provider Identifier (NPI) for this service line.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 4 Rendering Provider NPI (Alternate Box)\\\",\\\"description\\\":\\\"Enter the rendering provider's National Provider Identifier (NPI) for this service line if the form uses this second identifier box.\\\",\\\"group\\\":\\\"Fourth Service Line (Item 24 - Row 4)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"From Date of Service - Month\\\",\\\"description\\\":\\\"Enter the month portion of the start date for this fifth service line.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"From Date of Service - Day\\\",\\\"description\\\":\\\"Enter the day portion of the start date for this fifth service line.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"From Date of Service - Year\\\",\\\"description\\\":\\\"Enter the year portion of the start date for this fifth service line.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"To Date of Service - Month\\\",\\\"description\\\":\\\"Enter the month portion of the end date for this fifth service line (if different from the from date).\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"To Date of Service - Day\\\",\\\"description\\\":\\\"Enter the day portion of the end date for this fifth service line (if different from the from date).\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"To Date of Service - Year\\\",\\\"description\\\":\\\"Enter the year portion of the end date for this fifth service line (if different from the from date).\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Place of Service\\\",\\\"description\\\":\\\"Enter the place of service code for where the service was provided on this fifth service line.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Emergency Indicator (EMG)\\\",\\\"description\\\":\\\"Enter the emergency indicator value for this fifth service line, if applicable.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Procedure/Service Code (CPT/HCPCS)\\\",\\\"description\\\":\\\"Enter the CPT/HCPCS procedure or service code for this fifth service line.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Modifier 1\\\",\\\"description\\\":\\\"Enter the first procedure modifier associated with the CPT/HCPCS code on this fifth service line, if any.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Modifier 2\\\",\\\"description\\\":\\\"Enter the second procedure modifier associated with the CPT/HCPCS code on this fifth service line, if any.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Modifier 3\\\",\\\"description\\\":\\\"Enter the third procedure modifier associated with the CPT/HCPCS code on this fifth service line, if any.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Modifier 4\\\",\\\"description\\\":\\\"Enter the fourth procedure modifier associated with the CPT/HCPCS code on this fifth service line, if any.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Diagnosis Pointer\\\",\\\"description\\\":\\\"Enter the diagnosis pointer(s) (letters/numbers that reference the diagnoses listed in Item 21) that apply to this fifth service line.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Line Item Charges\\\",\\\"description\\\":\\\"Enter the charge amount billed for this fifth service line.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Days or Units\\\",\\\"description\\\":\\\"Enter the number of days or units for the service billed on this fifth service line.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"EPSDT Indicator\\\",\\\"description\\\":\\\"Enter the EPSDT indicator value for this fifth service line, if applicable.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Family Plan Indicator\\\",\\\"description\\\":\\\"Enter the family plan indicator value for this fifth service line, if applicable.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Rendering Provider ID Qualifier\\\",\\\"description\\\":\\\"Enter the qualifier that identifies the type of rendering provider ID reported for this fifth service line.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Rendering Provider ID (Non-NPI)\\\",\\\"description\\\":\\\"Enter the rendering provider's non-NPI identifier for this fifth service line, if required.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Rendering Provider NPI\\\",\\\"description\\\":\\\"Enter the rendering provider's National Provider Identifier (NPI) for this fifth service line.\\\",\\\"group\\\":\\\"Fifth Service Line (Item 24 - Row 5)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 From Date (Month)\\\",\\\"description\\\":\\\"Enter the month of the beginning date of service for the sixth service line.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 From Date (Day)\\\",\\\"description\\\":\\\"Enter the day of the beginning date of service for the sixth service line.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 From Date (Year)\\\",\\\"description\\\":\\\"Enter the year of the beginning date of service for the sixth service line.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 To Date (Month)\\\",\\\"description\\\":\\\"Enter the month of the ending date of service for the sixth service line.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 To Date (Day)\\\",\\\"description\\\":\\\"Enter the day of the ending date of service for the sixth service line.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 To Date (Year)\\\",\\\"description\\\":\\\"Enter the year of the ending date of service for the sixth service line.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 Place of Service Code\\\",\\\"description\\\":\\\"Enter the place of service code that identifies where the service was provided for the sixth service line.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 EMG Indicator\\\",\\\"description\\\":\\\"Enter the emergency indicator value for the sixth service line, if applicable.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 CPT/HCPCS Code\\\",\\\"description\\\":\\\"Enter the CPT or HCPCS procedure code for the service billed on the sixth service line.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 Modifier 1\\\",\\\"description\\\":\\\"Enter the first procedure modifier that applies to the CPT/HCPCS code on the sixth service line, if any.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 Modifier 2\\\",\\\"description\\\":\\\"Enter the second procedure modifier that applies to the CPT/HCPCS code on the sixth service line, if any.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 Modifier 3\\\",\\\"description\\\":\\\"Enter the third procedure modifier that applies to the CPT/HCPCS code on the sixth service line, if any.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 Modifier 4\\\",\\\"description\\\":\\\"Enter the fourth procedure modifier that applies to the CPT/HCPCS code on the sixth service line, if any.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 Diagnosis Pointer\\\",\\\"description\\\":\\\"Enter the diagnosis reference letter(s)/number(s) that link this service to the diagnoses listed in Item 21.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 Charge Amount\\\",\\\"description\\\":\\\"Enter the total charge amount being billed for the sixth service line.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 Days or Units\\\",\\\"description\\\":\\\"Enter the number of days or units for the service billed on the sixth service line.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 EPSDT Indicator\\\",\\\"description\\\":\\\"Enter the EPSDT indicator value for the sixth service line, if applicable.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 Family Plan Indicator\\\",\\\"description\\\":\\\"Enter the family plan indicator value for the sixth service line, if applicable.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 Rendering Provider ID Qualifier\\\",\\\"description\\\":\\\"Enter the qualifier that identifies the type of non-NPI rendering provider identifier reported for the sixth service line, if applicable.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 Rendering Provider Other ID\\\",\\\"description\\\":\\\"Enter the rendering provider’s non-NPI identifier for the sixth service line, if applicable.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Line 6 Rendering Provider NPI\\\",\\\"description\\\":\\\"Enter the rendering provider’s NPI for the sixth service line.\\\",\\\"group\\\":\\\"Sixth Service Line (Item 24 - Row 6)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Federal Tax ID Number\\\",\\\"description\\\":\\\"Enter the billing provider’s Federal Tax Identification Number (TIN).\\\",\\\"group\\\":\\\"Tax ID, Patient Account & Claim Totals (Items 25-30)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Federal Tax ID Type: SSN\\\",\\\"description\\\":\\\"Check this box if the Federal Tax ID number entered in Item 25 is a Social Security Number (SSN).\\\",\\\"group\\\":\\\"Tax ID, Patient Account & Claim Totals (Items 25-30)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Federal Tax ID Type: EIN\\\",\\\"description\\\":\\\"Check this box if the Federal Tax ID number entered in Item 25 is an Employer Identification Number (EIN).\\\",\\\"group\\\":\\\"Tax ID, Patient Account & Claim Totals (Items 25-30)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Patient Account Number\\\",\\\"description\\\":\\\"Enter the patient’s account number used by the provider or facility to identify this claim.\\\",\\\"group\\\":\\\"Tax ID, Patient Account & Claim Totals (Items 25-30)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Accept Assignment: Yes\\\",\\\"description\\\":\\\"Check this box if the provider accepts assignment of benefits for this claim.\\\",\\\"group\\\":\\\"Tax ID, Patient Account & Claim Totals (Items 25-30)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Accept Assignment: No\\\",\\\"description\\\":\\\"Check this box if the provider does not accept assignment of benefits for this claim.\\\",\\\"group\\\":\\\"Tax ID, Patient Account & Claim Totals (Items 25-30)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Total Charge\\\",\\\"description\\\":\\\"Enter the total charges for all services reported on this claim.\\\",\\\"group\\\":\\\"Tax ID, Patient Account & Claim Totals (Items 25-30)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Amount Paid\\\",\\\"description\\\":\\\"Enter the amount already paid toward this claim by the patient and/or other sources.\\\",\\\"group\\\":\\\"Tax ID, Patient Account & Claim Totals (Items 25-30)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Reserved for NUCC Use (Part 1)\\\",\\\"description\\\":\\\"Enter any information required by NUCC or the payer for the first reserved segment of Item 30.\\\",\\\"group\\\":\\\"Tax ID, Patient Account & Claim Totals (Items 25-30)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Reserved for NUCC Use (Part 2)\\\",\\\"description\\\":\\\"Enter any information required by NUCC or the payer for the second reserved segment of Item 30.\\\",\\\"group\\\":\\\"Tax ID, Patient Account & Claim Totals (Items 25-30)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Reserved for NUCC Use (Part 3)\\\",\\\"description\\\":\\\"Enter any information required by NUCC or the payer for the third reserved segment of Item 30.\\\",\\\"group\\\":\\\"Tax ID, Patient Account & Claim Totals (Items 25-30)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Reserved for NUCC Use (Part 4)\\\",\\\"description\\\":\\\"Enter any information required by NUCC or the payer for the fourth reserved segment of Item 30.\\\",\\\"group\\\":\\\"Tax ID, Patient Account & Claim Totals (Items 25-30)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Physician/Supplier Signature\\\",\\\"description\\\":\\\"Enter the signature of the physician or supplier (including degrees or credentials) certifying the claim.\\\",\\\"group\\\":\\\"Physician/Supplier Signature (Item 31)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Signature Date\\\",\\\"description\\\":\\\"Enter the date the physician or supplier signed the claim.\\\",\\\"group\\\":\\\"Physician/Supplier Signature (Item 31)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Facility Name and Address\\\",\\\"description\\\":\\\"Enter the name and full address of the facility where the services were provided (street, city, state, and ZIP code).\\\",\\\"group\\\":\\\"Service Facility Location (Item 32)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Facility NPI\\\",\\\"description\\\":\\\"Enter the National Provider Identifier (NPI) for the service facility.\\\",\\\"group\\\":\\\"Service Facility Location (Item 32)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Service Facility Other ID\\\",\\\"description\\\":\\\"Enter any additional identification number for the service facility (if applicable).\\\",\\\"group\\\":\\\"Service Facility Location (Item 32)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Billing Provider Phone Area Code\\\",\\\"description\\\":\\\"Enter the area code portion of the billing provider’s phone number.\\\",\\\"group\\\":\\\"Billing Provider Info & Phone (Item 33)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Billing Provider Phone Number\\\",\\\"description\\\":\\\"Enter the remaining digits of the billing provider’s phone number.\\\",\\\"group\\\":\\\"Billing Provider Info & Phone (Item 33)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Billing Provider Name and Address\\\",\\\"description\\\":\\\"Enter the billing provider’s name and mailing address (and other identifying details as needed) as shown in Item 33.\\\",\\\"group\\\":\\\"Billing Provider Info & Phone (Item 33)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Billing Provider NPI (33a)\\\",\\\"description\\\":\\\"Enter the billing provider’s National Provider Identifier (NPI).\\\",\\\"group\\\":\\\"Billing Provider Info & Phone (Item 33)\\\",\\\"page_num\\\":0},{\\\"name\\\":\\\"Billing Provider Other ID (33b)\\\",\\\"description\\\":\\\"Enter the billing provider’s other identifier (if applicable) as required by the payer.\\\",\\\"group\\\":\\\"Billing Provider Info & Phone (Item 33)\\\",\\\"page_num\\\":0}]}\",\"mcpMeta\":{\"structuredContent\":{\"session_id\":\"6a31926c7577317a2d1300be\",\"form_id\":\"6a3185a67577317a2d1300ae\",\"fields\":[{\"name\":\"PICA Code (Left)\",\"description\":\"Enter the Payer/Carrier Code (PICA) shown on your insurance card or provided by your plan for this claim.\",\"group\":\"Payer/Carrier Codes (PICA)\",\"page_num\":0},{\"name\":\"PICA1 (top left)\",\"page_num\":0},{\"name\":\"PICA2 (top left)\",\"page_num\":0},{\"name\":\"PICA3 (top left)\",\"page_num\":0},{\"name\":\"PICA Code (Right)\",\"description\":\"Enter the Payer/Carrier Code (PICA) for the carrier receiving this claim, if a separate PICA code is required.\",\"group\":\"Payer/Carrier Codes (PICA)\",\"page_num\":0},{\"name\":\"PICA1 (top right)\",\"page_num\":0},{\"name\":\"PICA2 (top right)\",\"page_num\":0},{\"name\":\"PICA3 (top right)\",\"page_num\":0},{\"name\":\"Medicare\",\"description\":\"Check this box if the patient’s coverage for this claim is through Medicare.\",\"group\":\"Insurance Program Selection\",\"page_num\":0},{\"name\":\"Medicaid\",\"description\":\"Check this box if the patient’s coverage for this claim is through Medicaid.\",\"group\":\"Insurance Program Selection\",\"page_num\":0},{\"name\":\"TRICARE\",\"description\":\"Check this box if the patient’s coverage for this claim is through TRICARE.\",\"group\":\"Insurance Program Selection\",\"page_num\":0},{\"name\":\"CHAMPVA\",\"description\":\"Check this box if the patient’s coverage for this claim is through CHAMPVA.\",\"group\":\"Insurance Program Selection\",\"page_num\":0},{\"name\":\"Group Health Plan\",\"description\":\"Check this box if the patient’s coverage for this claim is through a Group Health Plan.\",\"group\":\"Insurance Program Selection\",\"page_num\":0},{\"name\":\"FECA / Black Lung\",\"description\":\"Check this box if the claim is covered under FECA or the Black Lung program.\",\"group\":\"Insurance Program Selection\",\"page_num\":0},{\"name\":\"Other\",\"description\":\"Check this box if the patient’s coverage for this claim is through another program not listed and enter the program ID number.\",\"group\":\"Insurance Program Selection\",\"page_num\":0},{\"name\":\"Insured ID Number\",\"description\":\"Enter the insured person’s identification number exactly as shown on the insurance card. Fill only if 'Medicare', 'Medicaid', 'TRICARE', 'CHAMPVA', 'Group Health Plan', 'FECA / Black Lung', 'Other' is 'Yes' (any).\",\"group\":\"Patient & Insured Basic Info\",\"page_num\":0},{\"name\":\"Patient Name\",\"description\":\"Enter the patient’s full name (last name, first name, and middle initial).\",\"group\":\"Patient & Insured Basic Info\",\"page_num\":0},{\"name\":\"Patient Birth Month\",\"description\":\"Enter the month of the patient’s date of birth.\",\"group\":\"Patient & Insured Basic Info\",\"page_num\":0},{\"name\":\"Patient Birth Day\",\"description\":\"Enter the day of the month of the patient’s date of birth.\",\"group\":\"Patient & Insured Basic Info\",\"page_num\":0},{\"name\":\"Patient Birth Year\",\"description\":\"Enter the year of the patient’s date of birth.\",\"group\":\"Patient & Insured Basic Info\",\"page_num\":0},{\"name\":\"Sex: Male\",\"description\":\"Check this box if the patient is male.\",\"group\":\"Patient & Insured Basic Info\",\"page_num\":0},{\"name\":\"Sex: Female\",\"description\":\"Check this box if the patient is female.\",\"group\":\"Patient & Insured Basic Info\",\"page_num\":0},{\"name\":\"Insured Name\",\"description\":\"Enter the insured person’s full name (last name, first name, and middle initial).\",\"group\":\"Patient & Insured Basic Info\",\"page_num\":0},{\"name\":\"Patient Street Address\",\"description\":\"Enter the patient's street address (house/building number and street name).\",\"group\":\"Patient Address & Phone\",\"page_num\":0},{\"name\":\"Patient City\",\"description\":\"Enter the city where the patient lives.\",\"group\":\"Patient Address & Phone\",\"page_num\":0},{\"name\":\"Patient State\",\"description\":\"Enter the state where the patient lives.\",\"group\":\"Patient Address & Phone\",\"page_num\":0},{\"name\":\"Patient ZIP Code\",\"description\":\"Enter the patient's ZIP or postal code.\",\"group\":\"Patient Address & Phone\",\"page_num\":0},{\"name\":\"Patient Telephone (Area Code)\",\"description\":\"Enter the area code for the patient's telephone number.\",\"group\":\"Patient Address & Phone\",\"page_num\":0},{\"name\":\"Patient Telephone Number\",\"description\":\"Enter the patient's telephone number.\",\"group\":\"Patient Address & Phone\",\"page_num\":0},{\"name\":\"Self\",\"description\":\"Check this box if the patient is the insured person (the policyholder).\",\"group\":\"Patient Relationship to Insured\",\"page_num\":0},{\"name\":\"Spouse\",\"description\":\"Check this box if the patient is the insured person’s spouse.\",\"group\":\"Patient Relationship to Insured\",\"page_num\":0},{\"name\":\"Child\",\"description\":\"Check this box if the patient is the insured person’s child (dependent).\",\"group\":\"Patient Relationship to Insured\",\"page_num\":0},{\"name\":\"Other\",\"description\":\"Check this box if the patient’s relationship to the insured is not self, spouse, or child.\",\"group\":\"Patient Relationship to Insured\",\"page_num\":0},{\"name\":\"Insured Street Address\",\"description\":\"Enter the insured’s street address (number and street name).\",\"group\":\"Insured Address & Phone\",\"page_num\":0},{\"name\":\"Insured City\",\"description\":\"Enter the city for the insured’s mailing address.\",\"group\":\"Insured Address & Phone\",\"page_num\":0},{\"name\":\"Insured State\",\"description\":\"Enter the state for the insured’s mailing address.\",\"group\":\"Insured Address & Phone\",\"page_num\":0},{\"name\":\"Insured ZIP Code\",\"description\":\"Enter the ZIP code for the insured’s mailing address.\",\"group\":\"Insured Address & Phone\",\"page_num\":0},{\"name\":\"Insured Phone Area Code\",\"description\":\"Enter the area code for the insured’s telephone number.\",\"group\":\"Insured Address & Phone\",\"page_num\":0},{\"name\":\"Insured Phone Number\",\"description\":\"Enter the insured’s telephone number excluding the area code.\",\"group\":\"Insured Address & Phone\",\"page_num\":0},{\"name\":\"NUCC Use (Item 8)\",\"description\":\"Enter any code or information provided by NUCC for Item 8, if applicable; otherwise leave blank.\",\"group\":\"Reserved for NUCC Use (Item 8)\",\"page_num\":0},{\"name\":\"Other Insured Name\",\"description\":\"Enter the other insured person’s full name (last name, first name, middle initial) as it appears on their insurance card. Fill only if 'Yes' is 'Yes'.\",\"group\":\"Other Insured Information\",\"page_num\":0},{\"name\":\"Other Insured Policy/Group Number\",\"description\":\"Enter the policy number or group number for the other insured person’s health plan. Fill only if 'Yes' is 'Yes'.\",\"group\":\"Other Insured Information\",\"page_num\":0},{\"name\":\"Reserved for NUCC Use (9b)\",\"description\":\"Enter the value requested for this reserved NUCC field, if instructed to do so by the payer. Fill only if 'Yes' is 'Yes'.\",\"group\":\"Other Insured Information\",\"page_num\":0},{\"name\":\"Reserved for NUCC Use (9c)\",\"description\":\"Enter the value requested for this reserved NUCC field, if instructed to do so by the payer. Fill only if 'Yes' is 'Yes'.\",\"group\":\"Other Insured Information\",\"page_num\":0},{\"name\":\"Other Insurance Plan/Program Name\",\"description\":\"Enter the name of the other insured person’s insurance plan or program. Fill only if 'Yes' is 'Yes'.\",\"group\":\"Other Insured Information\",\"page_num\":0},{\"name\":\"Employment? (Current or Previous) — Yes\",\"description\":\"Check this box if the patient’s condition is related to current or previous employment.\",\"group\":\"Patient Condition Related To (Employment/Accidents)\",\"page_num\":0},{\"name\":\"Employment? (Current or Previous) — No\",\"description\":\"Check this box if the patient’s condition is not related to current or previous employment.\",\"group\":\"Patient Condition Related To (Employment/Accidents)\",\"page_num\":0},{\"name\":\"Auto Accident? — Yes\",\"description\":\"Check this box if the patient’s condition is related to an automobile accident.\",\"group\":\"Patient Condition Related To (Employment/Accidents)\",\"page_num\":0},{\"name\":\"Auto Accident? — No\",\"description\":\"Check this box if the patient’s condition is not related to an automobile accident.\",\"group\":\"Patient Condition Related To (Employment/Accidents)\",\"page_num\":0},{\"name\":\"Auto Accident Location (State)\",\"description\":\"Enter the U.S. state where the auto accident occurred, if the patient’s condition is related to an auto accident. Fill only if 'Auto Accident? — Yes' is 'Yes'.\",\"group\":\"Patient Condition Related To (Employment/Accidents)\",\"page_num\":0},{\"name\":\"Other Accident? — Yes\",\"description\":\"Check this box if the patient’s condition is related to an accident other than an auto accident.\",\"group\":\"Patient Condition Related To (Employment/Accidents)\",\"page_num\":0},{\"name\":\"Other Accident? — No\",\"description\":\"Check this box if the patient’s condition is not related to any accident other than an auto accident.\",\"group\":\"Patient Condition Related To (Employment/Accidents)\",\"page_num\":0},{\"name\":\"Claim Codes (10d)\",\"description\":\"Enter any applicable claim codes for this claim as designated by the NUCC.\",\"group\":\"Claim Codes (10d)\",\"page_num\":0},{\"name\":\"Insured Policy Group or FECA Number\",\"description\":\"Enter the insured person’s policy group number or FECA number as shown on the insurance information.\",\"group\":\"Insured Policy & Demographics\",\"page_num\":0},{\"name\":\"Insured Date of Birth (Month)\",\"description\":\"Enter the month of the insured person’s date of birth.\",\"group\":\"Insured Policy & Demographics\",\"page_num\":0},{\"name\":\"Insured Date of Birth (Day)\",\"description\":\"Enter the day of the month of the insured person’s date of birth.\",\"group\":\"Insured Policy & Demographics\",\"page_num\":0},{\"name\":\"Insured Date of Birth (Year)\",\"description\":\"Enter the year of the insured person’s date of birth.\",\"group\":\"Insured Policy & Demographics\",\"page_num\":0},{\"name\":\"Sex - Male (M)\",\"description\":\"Check this box if the insured person is male.\",\"group\":\"Insured Policy & Demographics\",\"page_num\":0},{\"name\":\"Sex - Female (F)\",\"description\":\"Check this box if the insured person is female.\",\"group\":\"Insured Policy & Demographics\",\"page_num\":0},{\"name\":\"Other Claim ID Qualifier\",\"description\":\"Enter the qualifier code that identifies the type/source of the other claim ID.\",\"group\":\"Other Claim ID & Plan Name\",\"page_num\":0},{\"name\":\"Other Claim ID\",\"description\":\"Enter the other claim identification number associated with the patient’s coverage.\",\"group\":\"Other Claim ID & Plan Name\",\"page_num\":0},{\"name\":\"Other Insurance Plan Name\",\"description\":\"Enter the name of the other insurance plan or program related to the other claim.\",\"group\":\"Other Claim ID & Plan Name\",\"page_num\":0},{\"name\":\"Yes\",\"description\":\"Check this box if the patient is covered by another health benefit plan in addition to the plan listed on this claim.\",\"group\":\"Another Health Benefit Plan (11d)\",\"page_num\":0},{\"name\":\"No\",\"description\":\"Check this box if the patient is not covered by any other health benefit plan besides the plan listed on this claim.\",\"group\":\"Another Health Benefit Plan (11d)\",\"page_num\":0},{\"name\":\"Patient/Authorized Person Signature\",\"description\":\"Enter the signature of the patient or the authorized person who is signing to authorize release of information and payment of benefits.\",\"group\":\"Patient/Insured Signatures & Dates\",\"page_num\":0},{\"name\":\"Signature Date (Patient/Authorized Person)\",\"description\":\"Enter the date the patient or authorized person signed the form.\",\"group\":\"Patient/Insured Signatures & Dates\",\"page_num\":0},{\"name\":\"Insured/Authorized Person Signature\",\"description\":\"Enter the signature of the insured or authorized person authorizing payment of medical benefits to the provider or supplier.\",\"group\":\"Patient/Insured Signatures & Dates\",\"page_num\":0},{\"name\":\"Current Illness/Injury Date - Month\",\"description\":\"Enter the month of the date of current illness, injury, or pregnancy (LMP).\",\"group\":\"Illness/Injury/Other Dates (Items 14-15)\",\"page_num\":0},{\"name\":\"Current Illness/Injury Date - Day\",\"description\":\"Enter the day of the date of current illness, injury, or pregnancy (LMP).\",\"group\":\"Illness/Injury/Other Dates (Items 14-15)\",\"page_num\":0},{\"name\":\"Current Illness/Injury Date - Year\",\"description\":\"Enter the year of the date of current illness, injury, or pregnancy (LMP).\",\"group\":\"Illness/Injury/Other Dates (Items 14-15)\",\"page_num\":0},{\"name\":\"Current Illness/Injury Date Qualifier\",\"description\":\"Enter the qualifier code that indicates what the date of current illness, injury, or pregnancy represents.\",\"group\":\"Illness/Injury/Other Dates (Items 14-15)\",\"page_num\":0},{\"name\":\"Other Date Qualifier\",\"description\":\"Enter the qualifier code that indicates what the other date represents.\",\"group\":\"Illness/Injury/Other Dates (Items 14-15)\",\"page_num\":0},{\"name\":\"Other Date - Month\",\"description\":\"Enter the month for the other date indicated by the qualifier.\",\"group\":\"Illness/Injury/Other Dates (Items 14-15)\",\"page_num\":0},{\"name\":\"Other Date - Day\",\"description\":\"Enter the day for the other date indicated by the qualifier.\",\"group\":\"Illness/Injury/Other Dates (Items 14-15)\",\"page_num\":0},{\"name\":\"Other Date - Year\",\"description\":\"Enter the year for the other date indicated by the qualifier.\",\"group\":\"Illness/Injury/Other Dates (Items 14-15)\",\"page_num\":0},{\"name\":\"Unable to Work From (Month)\",\"description\":\"Enter the month when the patient first became unable to work in their current occupation.\",\"group\":\"Unable to Work Dates (Item 16)\",\"page_num\":0},{\"name\":\"Unable to Work From (Day)\",\"description\":\"Enter the day of the month when the patient first became unable to work in their current occupation.\",\"group\":\"Unable to Work Dates (Item 16)\",\"page_num\":0},{\"name\":\"Unable to Work From (Year)\",\"description\":\"Enter the year when the patient first became unable to work in their current occupation.\",\"group\":\"Unable to Work Dates (Item 16)\",\"page_num\":0},{\"name\":\"Unable to Work To (Month)\",\"description\":\"Enter the month when the patient returned to work (or the end month of the period they were unable to work).\",\"group\":\"Unable to Work Dates (Item 16)\",\"page_num\":0},{\"name\":\"Unable to Work To (Day)\",\"description\":\"Enter the day of the month when the patient returned to work (or the end day of the period they were unable to work).\",\"group\":\"Unable to Work Dates (Item 16)\",\"page_num\":0},{\"name\":\"Unable to Work To (Year)\",\"description\":\"Enter the year when the patient returned to work (or the end year of the period they were unable to work).\",\"group\":\"Unable to Work Dates (Item 16)\",\"page_num\":0},{\"name\":\"Referring provider last name\",\"description\":\"Enter the referring provider’s last name.\",\"group\":\"Referring Provider Information (Item 17)\",\"page_num\":0},{\"name\":\"Referring provider first name\",\"description\":\"Enter the referring provider’s first name (and middle initial if applicable).\",\"group\":\"Referring Provider Information (Item 17)\",\"page_num\":0},{\"name\":\"Referring provider ID qualifier (17a)\",\"description\":\"Enter the qualifier that identifies the type of non-NPI referring provider ID reported in Item 17a.\",\"group\":\"Referring Provider Information (Item 17)\",\"page_num\":0},{\"name\":\"Referring provider ID number (17a)\",\"description\":\"Enter the referring provider’s non-NPI identification number corresponding to the qualifier in Item 17a.\",\"group\":\"Referring Provider Information (Item 17)\",\"page_num\":0},{\"name\":\"Referring provider NPI (17b)\",\"description\":\"Enter the referring provider’s National Provider Identifier (NPI).\",\"group\":\"Referring Provider Information (Item 17)\",\"page_num\":0},{\"name\":\"Hospitalization From - Month\",\"description\":\"Enter the month the hospitalization began (FROM date).\",\"group\":\"Hospitalization Dates (Item 18)\",\"page_num\":0},{\"name\":\"Hospitalization From - Day\",\"description\":\"Enter the day of the month the hospitalization began (FROM date).\",\"group\":\"Hospitalization Dates (Item 18)\",\"page_num\":0},{\"name\":\"Hospitalization From - Year\",\"description\":\"Enter the year the hospitalization began (FROM date).\",\"group\":\"Hospitalization Dates (Item 18)\",\"page_num\":0},{\"name\":\"Hospitalization To - Month\",\"description\":\"Enter the month the hospitalization ended (TO date). Fill only if 'Hospitalization From - Day' is 'Yes'.\",\"group\":\"Hospitalization Dates (Item 18)\",\"page_num\":0},{\"name\":\"Hospitalization To - Day\",\"description\":\"Enter the day of the month the hospitalization ended (TO date).\",\"group\":\"Hospitalization Dates (Item 18)\",\"page_num\":0},{\"name\":\"Hospitalization To - Year\",\"description\":\"Enter the year the hospitalization ended (TO date).\",\"group\":\"Hospitalization Dates (Item 18)\",\"page_num\":0},{\"name\":\"Additional Claim Information\",\"description\":\"Enter any additional claim information or remarks designated by NUCC that apply to this claim.\",\"group\":\"Additional Claim Info & Outside Lab (Items 19-20)\",\"page_num\":0},{\"name\":\"Outside Lab: Yes\",\"description\":\"Check this box if the lab work for this claim was performed by an outside (non-office) laboratory.\",\"group\":\"Additional Claim Info & Outside Lab (Items 19-20)\",\"page_num\":0},{\"name\":\"Outside Lab: No\",\"description\":\"Check this box if the lab work for this claim was not performed by an outside laboratory.\",\"group\":\"Additional Claim Info & Outside Lab (Items 19-20)\",\"page_num\":0},{\"name\":\"Outside Lab Indicator\",\"description\":\"Indicate whether the services were performed by an outside laboratory (e.g., enter Yes or No).\",\"group\":\"Additional Claim Info & Outside Lab (Items 19-20)\",\"page_num\":0},{\"name\":\"Outside Lab Charges\",\"description\":\"Enter the total charges amount for services performed by an outside laboratory.\",\"group\":\"Additional Claim Info & Outside Lab (Items 19-20)\",\"page_num\":0},{\"name\":\"ICD Indicator\",\"description\":\"Enter the ICD code set indicator that applies to the diagnosis codes listed (as required by the form).\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Diagnosis Code A\",\"description\":\"Enter the primary diagnosis code (A) describing the patient’s illness or injury.\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Diagnosis Code B\",\"description\":\"Enter diagnosis code B describing the patient’s illness or injury.\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Diagnosis Code C\",\"description\":\"Enter diagnosis code C describing the patient’s illness or injury.\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Diagnosis Code D\",\"description\":\"Enter diagnosis code D describing the patient’s illness or injury.\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Diagnosis Code E\",\"description\":\"Enter diagnosis code E describing the patient’s illness or injury.\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Diagnosis Code F\",\"description\":\"Enter diagnosis code F describing the patient’s illness or injury.\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Diagnosis Code G\",\"description\":\"Enter diagnosis code G describing the patient’s illness or injury.\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Diagnosis Code H\",\"description\":\"Enter diagnosis code H describing the patient’s illness or injury.\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Diagnosis Code I\",\"description\":\"Enter diagnosis code I describing the patient’s illness or injury.\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Diagnosis Code J\",\"description\":\"Enter diagnosis code J describing the patient’s illness or injury.\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Diagnosis Code K\",\"description\":\"Enter diagnosis code K describing the patient’s illness or injury.\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Diagnosis Code L\",\"description\":\"Enter diagnosis code L describing the patient’s illness or injury.\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Diagnosis Code M\",\"description\":\"Enter an additional diagnosis code (M) describing the patient’s illness or injury, if applicable.\",\"group\":\"Diagnosis Information (Item 21)\",\"page_num\":0},{\"name\":\"Resubmission Code\",\"description\":\"Enter the code that indicates this claim is a resubmission or corrected/replacement claim, if applicable.\",\"group\":\"Resubmission & Original Reference (Item 22)\",\"page_num\":0},{\"name\":\"Original Reference Number\",\"description\":\"Enter the reference number or identifier for the original claim being resubmitted or corrected.\",\"group\":\"Resubmission & Original Reference (Item 22)\",\"page_num\":0},{\"name\":\"Prior Authorization Number\",\"description\":\"Enter the prior authorization number issued for the services being claimed (Item 23).\",\"group\":\"Prior Authorization Number (Item 23)\",\"page_num\":0},{\"name\":\"Service From Month\",\"description\":\"Enter the month of the start date of service for this service line.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Service From Day\",\"description\":\"Enter the day of the start date of service for this service line.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Service From Year\",\"description\":\"Enter the year of the start date of service for this service line.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Service To Month\",\"description\":\"Enter the month of the end date of service for this service line, if applicable.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Service To Day\",\"description\":\"Enter the day of the end date of service for this service line, if applicable.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Service To Year\",\"description\":\"Enter the year of the end date of service for this service line, if applicable.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Place of Service\",\"description\":\"Enter the place of service code that indicates where the service was provided.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Emergency Indicator\",\"description\":\"Enter the emergency indicator value for this service line, if required.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Procedure Code (CPT/HCPCS)\",\"description\":\"Enter the CPT or HCPCS procedure code for the service provided.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Modifier 1\",\"description\":\"Enter the first procedure modifier, if applicable.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Modifier 2\",\"description\":\"Enter the second procedure modifier, if applicable.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Modifier 3\",\"description\":\"Enter the third procedure modifier, if applicable.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Modifier 4\",\"description\":\"Enter the fourth procedure modifier, if applicable.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Diagnosis Pointer\",\"description\":\"Enter the diagnosis code reference(s) (pointer) that apply to this procedure.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Line Item Charges\",\"description\":\"Enter the total charge amount for this service line.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Days or Units\",\"description\":\"Enter the number of days or units billed for this service line.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"EPSDT/Family Plan\",\"description\":\"Enter the EPSDT or family planning indicator/code, if applicable.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Rendering Provider ID Qualifier\",\"description\":\"Enter the qualifier that identifies the type of non-NPI rendering provider identifier being reported.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Rendering Provider NPI\",\"description\":\"Enter the rendering provider’s National Provider Identifier (NPI) for this service line.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Row 1 — 24J Rendering Provider ID #\",\"description\":\"Enter the rendering provider's identifier for Row 1 (24J), for example the provider's NPI or other assigned ID.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Rendering Provider Other ID\",\"description\":\"Enter the rendering provider’s non-NPI identifier for this service line, if applicable.\",\"group\":\"First Service Line (Item 24 - Row 1)\",\"page_num\":0},{\"name\":\"Service Date From (Month)\",\"description\":\"Enter the month portion of the beginning date of service for the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Service Date From (Day)\",\"description\":\"Enter the day portion of the beginning date of service for the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Service Date From (Year)\",\"description\":\"Enter the year portion of the beginning date of service for the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Service Date To (Month)\",\"description\":\"Enter the month portion of the ending date of service for the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Service Date To (Day)\",\"description\":\"Enter the day portion of the ending date of service for the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Service Date To (Year)\",\"description\":\"Enter the year portion of the ending date of service for the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Place of Service Code\",\"description\":\"Enter the place of service code that identifies where the services were provided for the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Emergency Indicator (EMG)\",\"description\":\"Enter the emergency indicator value for the second service line, if applicable.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Procedure Code (CPT/HCPCS)\",\"description\":\"Enter the CPT or HCPCS procedure/service code for the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Procedure Modifier 1\",\"description\":\"Enter the first procedure modifier associated with the procedure code for the second service line, if any.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Procedure Modifier 2\",\"description\":\"Enter the second procedure modifier associated with the procedure code for the second service line, if any.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Procedure Modifier 3\",\"description\":\"Enter the third procedure modifier associated with the procedure code for the second service line, if any.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Procedure Modifier 4\",\"description\":\"Enter the fourth procedure modifier associated with the procedure code for the second service line, if any.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Diagnosis Pointer\",\"description\":\"Enter the diagnosis pointer(s) that link this service to the relevant diagnosis code(s) for the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Line Item Charge Amount\",\"description\":\"Enter the total charge amount being billed for the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Days or Units\",\"description\":\"Enter the number of days or units for the billed service on the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"EPSDT Indicator\",\"description\":\"Enter the EPSDT indicator value for the second service line, if applicable.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Family Planning Indicator\",\"description\":\"Enter the family planning indicator value for the second service line, if applicable.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Rendering Provider ID Qualifier\",\"description\":\"Enter the qualifier that identifies the type of rendering provider identifier reported for the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Rendering Provider NPI\",\"description\":\"Enter the rendering provider's NPI for the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"Rendering Provider Other ID\",\"description\":\"Enter the rendering provider's other identifier (non-NPI), if applicable, for the second service line.\",\"group\":\"Second Service Line (Item 24 - Row 2)\",\"page_num\":0},{\"name\":\"From Date of Service - Month\",\"description\":\"Enter the month of the start (FROM) date of service for this third service line.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"From Date of Service - Day\",\"description\":\"Enter the day of the start (FROM) date of service for this third service line.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"From Date of Service - Year\",\"description\":\"Enter the year of the start (FROM) date of service for this third service line.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"To Date of Service - Month\",\"description\":\"Enter the month of the end (TO) date of service for this third service line, if different from the from date.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"To Date of Service - Day\",\"description\":\"Enter the day of the end (TO) date of service for this third service line, if different from the from date.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"To Date of Service - Year\",\"description\":\"Enter the year of the end (TO) date of service for this third service line, if different from the from date.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Place of Service\",\"description\":\"Enter the place of service code for where the service was performed on this third service line.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Emergency Indicator\",\"description\":\"Enter the emergency indicator for this third service line, if applicable.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Procedure/Service Code (CPT/HCPCS)\",\"description\":\"Enter the CPT/HCPCS procedure or service code billed on this third service line.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Modifier 1\",\"description\":\"Enter the first procedure modifier for the CPT/HCPCS code on this third service line, if applicable.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Modifier 2\",\"description\":\"Enter the second procedure modifier for the CPT/HCPCS code on this third service line, if applicable.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Modifier 3\",\"description\":\"Enter the third procedure modifier for the CPT/HCPCS code on this third service line, if applicable.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Modifier 4\",\"description\":\"Enter the fourth procedure modifier for the CPT/HCPCS code on this third service line, if applicable.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Diagnosis Pointer\",\"description\":\"Enter the diagnosis code reference letter(s) (from Item 21) that apply to this third service line.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Charges - Dollars\",\"description\":\"Enter the dollar amount charged for this third service line.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Charges - Cents\",\"description\":\"Enter the cents portion of the amount charged for this third service line.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Days or Units\",\"description\":\"Enter the number of days or units for the service billed on this third service line.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"EPSDT/Family Plan\",\"description\":\"Enter the EPSDT/Family Plan indicator for this third service line, if applicable.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Rendering Provider ID Qualifier\",\"description\":\"Enter the qualifier that identifies the type of non-NPI rendering provider identifier reported for this third service line, if applicable.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Rendering Provider NPI\",\"description\":\"Enter the rendering provider's NPI for this third service line.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Rendering Provider Other ID\",\"description\":\"Enter the rendering provider's non-NPI identifier for this third service line, if applicable.\",\"group\":\"Third Service Line (Item 24 - Row 3)\",\"page_num\":0},{\"name\":\"Service Line 4 From Date (MM)\",\"description\":\"Enter the month of the start date for the service period on this service line.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 From Date (DD)\",\"description\":\"Enter the day of the start date for the service period on this service line.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 From Date (YY)\",\"description\":\"Enter the two-digit year of the start date for the service period on this service line.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 To Date (MM)\",\"description\":\"Enter the month of the end date for the service period on this service line.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 To Date (DD)\",\"description\":\"Enter the day of the end date for the service period on this service line.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 To Date (YY)\",\"description\":\"Enter the two-digit year of the end date for the service period on this service line.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Place of Service\",\"description\":\"Enter the place of service code that describes where the service was provided for this service line.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Emergency Indicator\",\"description\":\"Enter the emergency indicator value for this service line, if applicable.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Procedure Code (CPT/HCPCS)\",\"description\":\"Enter the CPT/HCPCS procedure code for the service or item billed on this service line.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Modifier 1\",\"description\":\"Enter the first procedure modifier associated with the billed procedure code on this service line, if any.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Modifier 2\",\"description\":\"Enter the second procedure modifier associated with the billed procedure code on this service line, if any.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Modifier 3\",\"description\":\"Enter the third procedure modifier associated with the billed procedure code on this service line, if any.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Modifier 4\",\"description\":\"Enter the fourth procedure modifier associated with the billed procedure code on this service line, if any.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Diagnosis Pointer\",\"description\":\"Enter the diagnosis pointer(s) that link this service line to the diagnosis code(s) listed in the diagnosis section.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Charges\",\"description\":\"Enter the total charge amount being billed for this service line.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Days or Units\",\"description\":\"Enter the number of days or units for the service billed on this service line.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 EPSDT/Family Plan\",\"description\":\"Enter the EPSDT or family planning indicator for this service line, if applicable.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Provider ID Qualifier\",\"description\":\"Enter the qualifier that identifies the type of provider ID reported for this service line, if applicable.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Rendering Provider ID (Non-NPI)\",\"description\":\"Enter the rendering provider's non-NPI identifier for this service line, if required by the payer.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Rendering Provider NPI\",\"description\":\"Enter the rendering provider's National Provider Identifier (NPI) for this service line.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"Service Line 4 Rendering Provider NPI (Alternate Box)\",\"description\":\"Enter the rendering provider's National Provider Identifier (NPI) for this service line if the form uses this second identifier box.\",\"group\":\"Fourth Service Line (Item 24 - Row 4)\",\"page_num\":0},{\"name\":\"From Date of Service - Month\",\"description\":\"Enter the month portion of the start date for this fifth service line.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"From Date of Service - Day\",\"description\":\"Enter the day portion of the start date for this fifth service line.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"From Date of Service - Year\",\"description\":\"Enter the year portion of the start date for this fifth service line.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"To Date of Service - Month\",\"description\":\"Enter the month portion of the end date for this fifth service line (if different from the from date).\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"To Date of Service - Day\",\"description\":\"Enter the day portion of the end date for this fifth service line (if different from the from date).\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"To Date of Service - Year\",\"description\":\"Enter the year portion of the end date for this fifth service line (if different from the from date).\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Place of Service\",\"description\":\"Enter the place of service code for where the service was provided on this fifth service line.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Emergency Indicator (EMG)\",\"description\":\"Enter the emergency indicator value for this fifth service line, if applicable.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Procedure/Service Code (CPT/HCPCS)\",\"description\":\"Enter the CPT/HCPCS procedure or service code for this fifth service line.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Modifier 1\",\"description\":\"Enter the first procedure modifier associated with the CPT/HCPCS code on this fifth service line, if any.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Modifier 2\",\"description\":\"Enter the second procedure modifier associated with the CPT/HCPCS code on this fifth service line, if any.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Modifier 3\",\"description\":\"Enter the third procedure modifier associated with the CPT/HCPCS code on this fifth service line, if any.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Modifier 4\",\"description\":\"Enter the fourth procedure modifier associated with the CPT/HCPCS code on this fifth service line, if any.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Diagnosis Pointer\",\"description\":\"Enter the diagnosis pointer(s) (letters/numbers that reference the diagnoses listed in Item 21) that apply to this fifth service line.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Line Item Charges\",\"description\":\"Enter the charge amount billed for this fifth service line.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Days or Units\",\"description\":\"Enter the number of days or units for the service billed on this fifth service line.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"EPSDT Indicator\",\"description\":\"Enter the EPSDT indicator value for this fifth service line, if applicable.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Family Plan Indicator\",\"description\":\"Enter the family plan indicator value for this fifth service line, if applicable.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Rendering Provider ID Qualifier\",\"description\":\"Enter the qualifier that identifies the type of rendering provider ID reported for this fifth service line.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Rendering Provider ID (Non-NPI)\",\"description\":\"Enter the rendering provider's non-NPI identifier for this fifth service line, if required.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Rendering Provider NPI\",\"description\":\"Enter the rendering provider's National Provider Identifier (NPI) for this fifth service line.\",\"group\":\"Fifth Service Line (Item 24 - Row 5)\",\"page_num\":0},{\"name\":\"Service Line 6 From Date (Month)\",\"description\":\"Enter the month of the beginning date of service for the sixth service line.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 From Date (Day)\",\"description\":\"Enter the day of the beginning date of service for the sixth service line.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 From Date (Year)\",\"description\":\"Enter the year of the beginning date of service for the sixth service line.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 To Date (Month)\",\"description\":\"Enter the month of the ending date of service for the sixth service line.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 To Date (Day)\",\"description\":\"Enter the day of the ending date of service for the sixth service line.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 To Date (Year)\",\"description\":\"Enter the year of the ending date of service for the sixth service line.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 Place of Service Code\",\"description\":\"Enter the place of service code that identifies where the service was provided for the sixth service line.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 EMG Indicator\",\"description\":\"Enter the emergency indicator value for the sixth service line, if applicable.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 CPT/HCPCS Code\",\"description\":\"Enter the CPT or HCPCS procedure code for the service billed on the sixth service line.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 Modifier 1\",\"description\":\"Enter the first procedure modifier that applies to the CPT/HCPCS code on the sixth service line, if any.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 Modifier 2\",\"description\":\"Enter the second procedure modifier that applies to the CPT/HCPCS code on the sixth service line, if any.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 Modifier 3\",\"description\":\"Enter the third procedure modifier that applies to the CPT/HCPCS code on the sixth service line, if any.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 Modifier 4\",\"description\":\"Enter the fourth procedure modifier that applies to the CPT/HCPCS code on the sixth service line, if any.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 Diagnosis Pointer\",\"description\":\"Enter the diagnosis reference letter(s)/number(s) that link this service to the diagnoses listed in Item 21.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 Charge Amount\",\"description\":\"Enter the total charge amount being billed for the sixth service line.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 Days or Units\",\"description\":\"Enter the number of days or units for the service billed on the sixth service line.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 EPSDT Indicator\",\"description\":\"Enter the EPSDT indicator value for the sixth service line, if applicable.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 Family Plan Indicator\",\"description\":\"Enter the family plan indicator value for the sixth service line, if applicable.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 Rendering Provider ID Qualifier\",\"description\":\"Enter the qualifier that identifies the type of non-NPI rendering provider identifier reported for the sixth service line, if applicable.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 Rendering Provider Other ID\",\"description\":\"Enter the rendering provider’s non-NPI identifier for the sixth service line, if applicable.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Service Line 6 Rendering Provider NPI\",\"description\":\"Enter the rendering provider’s NPI for the sixth service line.\",\"group\":\"Sixth Service Line (Item 24 - Row 6)\",\"page_num\":0},{\"name\":\"Federal Tax ID Number\",\"description\":\"Enter the billing provider’s Federal Tax Identification Number (TIN).\",\"group\":\"Tax ID, Patient Account & Claim Totals (Items 25-30)\",\"page_num\":0},{\"name\":\"Federal Tax ID Type: SSN\",\"description\":\"Check this box if the Federal Tax ID number entered in Item 25 is a Social Security Number (SSN).\",\"group\":\"Tax ID, Patient Account & Claim Totals (Items 25-30)\",\"page_num\":0},{\"name\":\"Federal Tax ID Type: EIN\",\"description\":\"Check this box if the Federal Tax ID number entered in Item 25 is an Employer Identification Number (EIN).\",\"group\":\"Tax ID, Patient Account & Claim Totals (Items 25-30)\",\"page_num\":0},{\"name\":\"Patient Account Number\",\"description\":\"Enter the patient’s account number used by the provider or facility to identify this claim.\",\"group\":\"Tax ID, Patient Account & Claim Totals (Items 25-30)\",\"page_num\":0},{\"name\":\"Accept Assignment: Yes\",\"description\":\"Check this box if the provider accepts assignment of benefits for this claim.\",\"group\":\"Tax ID, Patient Account & Claim Totals (Items 25-30)\",\"page_num\":0},{\"name\":\"Accept Assignment: No\",\"description\":\"Check this box if the provider does not accept assignment of benefits for this claim.\",\"group\":\"Tax ID, Patient Account & Claim Totals (Items 25-30)\",\"page_num\":0},{\"name\":\"Total Charge\",\"description\":\"Enter the total charges for all services reported on this claim.\",\"group\":\"Tax ID, Patient Account & Claim Totals (Items 25-30)\",\"page_num\":0},{\"name\":\"Amount Paid\",\"description\":\"Enter the amount already paid toward this claim by the patient and/or other sources.\",\"group\":\"Tax ID, Patient Account & Claim Totals (Items 25-30)\",\"page_num\":0},{\"name\":\"Reserved for NUCC Use (Part 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the signature of the physician or supplier (including degrees or credentials) certifying the claim.\",\"group\":\"Physician/Supplier Signature (Item 31)\",\"page_num\":0},{\"name\":\"Signature Date\",\"description\":\"Enter the date the physician or supplier signed the claim.\",\"group\":\"Physician/Supplier Signature (Item 31)\",\"page_num\":0},{\"name\":\"Service Facility Name and Address\",\"description\":\"Enter the name and full address of the facility where the services were provided (street, city, state, and ZIP code).\",\"group\":\"Service Facility Location (Item 32)\",\"page_num\":0},{\"name\":\"Service Facility NPI\",\"description\":\"Enter the National Provider Identifier (NPI) for the service facility.\",\"group\":\"Service Facility Location (Item 32)\",\"page_num\":0},{\"name\":\"Service Facility Other ID\",\"description\":\"Enter any additional identification number for the service facility (if applicable).\",\"group\":\"Service Facility Location (Item 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Instafill\",\"attributionMcpTool\":\"get_filled_form_data\",\"type\":\"assistant\",\"uuid\":\"1a210429-7cf1-4695-a371-e1e5160bc315\",\"timestamp\":\"2026-06-16T18:20:18.003Z\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"C:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"parentUuid\":\"1a210429-7cf1-4695-a371-e1e5160bc315\",\"isSidechain\":false,\"message\":{\"model\":\"claude-opus-4-8\",\"id\":\"msg_012CeEZ3jUKhDHHQfCgB5mVm\",\"type\":\"message\",\"role\":\"assistant\",\"content\":[{\"type\":\"text\",\"text\":\"The re-run completed. The structured-data endpoint for this form returns only field metadata (name/description/group), not the filled values, so I can't programmatically read back the phone string — but the fix itself is in place:\\n\\n**What changed:**\\n- **Insured Phone Number** (`f653`): type `Number` → `Text`. The `Number` type was formatting `5550192` as `5,550,192` with thousands separators. As `Text` it's stored verbatim.\\n- Re-fill on session `6a31926c7577317a2d1300be` completed with the corrected field type applied.\\n\\n**Confirm visually here:**\\n[https://instafill.ai/fill/6a3185a67577317a2d1300ae/6a31926c7577317a2d1300be](https://instafill.ai/fill/6a3185a67577317a2d1300ae/6a31926c7577317a2d1300be)\\n\\nBox 7's telephone should now read as plain text (`+1 (614) 555-0192`) instead of the number-formatted `5,550,192`.\\n\\nOne note for accuracy: this form splits the insured phone into two fields — **Insured Phone Area Code** (`d7f2`) and **Insured Phone Number** (`f653`) — so the line number portion lives in `f653`. If after viewing it still shows `5550192` without the `555-0192` dash, tell me and I can set an `example` on the field to lock the exact `555-0192` format. Want me to do that proactively?\"}],\"stop_reason\":\"end_turn\",\"stop_sequence\":null,\"stop_details\":null,\"usage\":{\"input_tokens\":2,\"cache_creation_input_tokens\":1042,\"cache_read_input_tokens\":54794,\"output_tokens\":1032,\"server_tool_use\":{\"web_search_requests\":0,\"web_fetch_requests\":0},\"service_tier\":\"standard\",\"cache_creation\":{\"ephemeral_1h_input_tokens\":1042,\"ephemeral_5m_input_tokens\":0},\"inference_geo\":\"not_available\",\"iterations\":[{\"input_tokens\":2,\"output_tokens\":1032,\"cache_read_input_tokens\":54794,\"cache_creation_input_tokens\":1042,\"cache_creation\":{\"ephemeral_5m_input_tokens\":0,\"ephemeral_1h_input_tokens\":1042},\"type\":\"message\"}],\"speed\":\"standard\"},\"diagnostics\":null},\"requestId\":\"req_011Cc7QDmi5AuByPvKu7PJ2F\",\"attributionMcpServer\":\"claude.ai Instafill\",\"attributionMcpTool\":\"get_filled_form_data\",\"type\":\"assistant\",\"uuid\":\"d31dccc2-a31b-44a1-8ea0-45eb13ad3b56\",\"timestamp\":\"2026-06-16T18:20:22.639Z\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"C:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"type\":\"queue-operation\",\"operation\":\"enqueue\",\"timestamp\":\"2026-06-16T18:21:24.016Z\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\"}\n{\"type\":\"queue-operation\",\"operation\":\"dequeue\",\"timestamp\":\"2026-06-16T18:21:24.017Z\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\"}\n{\"parentUuid\":\"d31dccc2-a31b-44a1-8ea0-45eb13ad3b56\",\"isSidechain\":false,\"promptId\":\"9be0ed6d-1a0a-4774-9c6e-9027b6cc4983\",\"type\":\"user\",\"message\":{\"role\":\"user\",\"content\":[{\"type\":\"text\",\"text\":\"do 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— applied proactively and re-filled.\\n\\n**What I changed on field `f653` (Insured Phone Number):**\\n- **Example added:** `555-0192` — locks the exact target format.\\n- **Description tightened:** instructs plain-text `NNN-NNNN` format, \\\"do not format as a number.\\\"\\n- Combined with the earlier `Number → Text` type change, the field now has both the right type *and* an explicit format anchor.\\n\\nRe-fill completed on session `6a31926c7577317a2d1300be`.\\n\\n**View / confirm:**\\n[https://instafill.ai/fill/6a3185a67577317a2d1300ae/6a31926c7577317a2d1300be](https://instafill.ai/fill/6a3185a67577317a2d1300ae/6a31926c7577317a2d1300be)\\n\\nBox 7's telephone should now read `+1 (614) 555-0192` (area code `614` in `d7f2`, line number `555-0192` in `f653`). 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After re-running the fill, box 7 rendered correctly as `+1 (614) 555-0192`.\\n\\nNote: box 7 phone is split across two fields — area code in `d7f2` (Text), line number in `f653`. 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After re-running the fill, box 7 rendered correctly as `+1 (614) 555-0192`.\\n\\nNote: box 7 phone is split across two fields — area code in `d7f2` (Text), line number in `f653`. 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changed to Text + example to lock NNN-NNNN\\n\",\"structuredPatch\":[],\"originalFile\":null,\"userModified\":false},\"sourceToolAssistantUUID\":\"0a383be6-d997-4ba3-8c2e-3555d552b18e\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"c:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"parentUuid\":\"14fb8b99-e31f-49dc-9a03-c95103d6e403\",\"isSidechain\":false,\"message\":{\"model\":\"claude-opus-4-8\",\"id\":\"msg_01WejRCd6sxNdCC5KQX9Eo4r\",\"type\":\"message\",\"role\":\"assistant\",\"content\":[{\"type\":\"text\",\"text\":\"Saved and ready.\\n\\n**📥 Download the filled PDF:**\\n[filled_6a31926c7577317a2d1300be.pdf](https://api.instafill.ai/mcp/uploads/download?token=1D1628FEBA13E67B985406C8036C780498F8D7A3C468E3A1EEFCB72702F5397D)\\n\\n⚠️ This link is **valid for 10 minutes and works only once** — open it now. If it expires, just ask and I'll generate a fresh one.\\n\\n**Saved to memory:** the CMS-1500 insured-phone fix — that field `f653` defaults to `Number` type (which mangled the phone as `5,550,192`), and the fix is `Number → Text` plus an example locking the `555-0192` format. I'll apply this knowledge automatically if the same field comes up again.\"}],\"stop_reason\":\"end_turn\",\"stop_sequence\":null,\"stop_details\":null,\"usage\":{\"input_tokens\":2,\"cache_creation_input_tokens\":309,\"cache_read_input_tokens\":62175,\"output_tokens\":271,\"server_tool_use\":{\"web_search_requests\":0,\"web_fetch_requests\":0},\"service_tier\":\"standard\",\"cache_creation\":{\"ephemeral_1h_input_tokens\":309,\"ephemeral_5m_input_tokens\":0},\"inference_geo\":\"not_available\",\"iterations\":[{\"input_tokens\":2,\"output_tokens\":271,\"cache_read_input_tokens\":62175,\"cache_creation_input_tokens\":309,\"cache_creation\":{\"ephemeral_5m_input_tokens\":0,\"ephemeral_1h_input_tokens\":309},\"type\":\"message\"}],\"speed\":\"standard\"},\"diagnostics\":null},\"requestId\":\"req_011Cc7QdxTQ6XJmhxph7Wmu1\",\"attributionMcpServer\":\"claude.ai Instafill\",\"attributionMcpTool\":\"download_filled_form\",\"type\":\"assistant\",\"uuid\":\"a6f9b946-39fc-4cd9-a9b4-c4523e73bcd6\",\"timestamp\":\"2026-06-16T18:25:39.138Z\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"c:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"type\":\"queue-operation\",\"operation\":\"enqueue\",\"timestamp\":\"2026-06-16T18:25:50.906Z\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\"}\n{\"type\":\"queue-operation\",\"operation\":\"dequeue\",\"timestamp\":\"2026-06-16T18:25:50.906Z\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\"}\n{\"parentUuid\":\"a6f9b946-39fc-4cd9-a9b4-c4523e73bcd6\",\"isSidechain\":false,\"promptId\":\"6b86964e-6f30-4f20-ac24-497001191dd4\",\"type\":\"user\",\"message\":{\"role\":\"user\",\"content\":\"instashare\\n/instashare\"},\"uuid\":\"b399b670-cbea-402a-b560-a547d1dfe4c9\",\"timestamp\":\"2026-06-16T18:25:50.941Z\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"c:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"parentUuid\":\"b399b670-cbea-402a-b560-a547d1dfe4c9\",\"isSidechain\":false,\"promptId\":\"6b86964e-6f30-4f20-ac24-497001191dd4\",\"type\":\"user\",\"message\":{\"role\":\"user\",\"content\":[{\"type\":\"text\",\"text\":\"Base directory for this skill: C:\\\\Users\\\\smirn\\\\.claude\\\\skills\\\\instashare\\n\\n# InstaShare\\n\\nUpload the current Claude Code session JSONL to the InstaShare API and report the public link. One shell call does it — the freshest `.jsonl` by mtime in the project's slug directory is reliably the active session.\\n\\nIf this session has already been shared in a previous run, the script reuses the existing URL: it reads a sidecar file `.instashare.json` (created by the first upload) and `PUT`s the new content to the same slug. The public URL stays the same so any link the user already pasted continues to work and now shows the latest transcript.\\n\\n## Configuration\\n\\n**No account required.** The first share creates an anonymous device identifier (`claim_token`) that the skill stores in `~/.claude/instashare/credentials.json`. Every subsequent share is grouped under the same device. The skill prints a one-time **claim link** so the user can sign in with Google later and pull every share from this device into a personal `/mine` page — past and future. Clicking the claim link is optional; the public share URLs work either way.\\n\\nEndpoint defaults to `https://instashare.to`. Override with the `INSTASHARE_API_URL` env var (use `http://localhost:3000` for local dev).\\n\\n## Fill in the session info\\n\\nThe shared page shows a header line like `Opus 4.8 (1M context) with medium effort · Claude Max`. Plan is read from `~/.claude.json` automatically and the model also has a server-side fallback parsed from the transcript, but **effort and the model's context-window marker live only in the running session** — so before you run the snippet, set two variables from *your own* current session:\\n\\n- `$sessionModel` / `session_model` → your current model exactly as shown in the status line, including any context-window marker, e.g. `Opus 4.8 (1M context)`.\\n- `$sessionEffort` / `session_effort` → your current reasoning effort, e.g. `medium` (the bare word, no \\\"effort\\\" suffix).\\n\\nIf you genuinely don't know one of them, leave it as the empty string — the page degrades gracefully (the server still fills in the model from the transcript; effort/plan are simply omitted). Don't guess or invent values.\\n\\n## Run exactly one of these\\n\\nPick by platform. The script computes the slug itself, finds the session, scrubs known secret patterns from the body in memory, decides POST-vs-PUT from the sidecar, uploads the scrubbed body, and prints the URL.\\n\\n### Windows (PowerShell)\\n\\n```powershell\\n$apiBase = if ($env:INSTASHARE_API_URL) { $env:INSTASHARE_API_URL } else { 'https://instashare.to' }\\n$credentialsDir = Join-Path $env:USERPROFILE \\\".claude\\\\instashare\\\"\\n$credentialsFile = Join-Path $credentialsDir \\\"credentials.json\\\"\\n$deviceHostname = $env:COMPUTERNAME\\n\\n# Session info shown in the shared-page header. Model and effort are live-session\\n# state only the running agent knows — BEFORE running, fill them from the current\\n# session (see \\\"Fill in the session info\\\" below); leave '' if unknown (the server\\n# falls back to the model parsed from the transcript). Plan is read from disk.\\n$sessionModel = '' # e.g. 'Opus 4.8 (1M context)'\\n$sessionEffort = '' # e.g. 'medium'\\n$sessionPlan = ''\\n$claudeConfig = Join-Path $env:USERPROFILE \\\".claude.json\\\"\\nif (Test-Path $claudeConfig) {\\n try {\\n $orgType = (Get-Content $claudeConfig -Raw -Encoding UTF8 | ConvertFrom-Json).oauthAccount.organizationType\\n switch ($orgType) {\\n 'claude_max' { $sessionPlan = 'Claude Max' }\\n 'claude_pro' { $sessionPlan = 'Claude Pro' }\\n 'claude_team' { $sessionPlan = 'Claude Team' }\\n 'claude_enterprise' { $sessionPlan = 'Claude Enterprise' }\\n }\\n } catch { }\\n}\\n\\n# Load the per-machine claim token if we have one. Server uses its hash to\\n# group every share from this device under a single identity so the user\\n# can later claim them all to an account.\\n$claimToken = $null\\nif (Test-Path $credentialsFile) {\\n try {\\n $claimToken = (Get-Content $credentialsFile -Raw -Encoding UTF8 | ConvertFrom-Json).claimToken\\n } catch { }\\n}\\n\\n$cwd = (Get-Location).Path\\n# Slug = cwd with ':' and '\\\\' replaced by '-'. .Replace (literal) avoids the\\n# doubled-backslash regex literal that the sandbox path guard can misread as a\\n# protected '\\\\\\\\' target (it pairs any such literal with a destructive cmdlet).\\n$slug = $cwd.Replace(':', '-').Replace('\\\\', '-')\\n$projDir = Join-Path $env:USERPROFILE \\\".claude\\\\projects\\\\$slug\\\"\\n$src = Get-ChildItem \\\"$projDir\\\\*.jsonl\\\" -ErrorAction Stop |\\n Sort-Object LastWriteTime -Descending | Select-Object -First 1\\n$body = Get-Content $src.FullName -Raw -Encoding UTF8\\n$sidecar = \\\"$($src.FullName).instashare.json\\\"\\n\\n# Redact common secrets before upload. Curated patterns only — provider-specific\\n# first so e.g. OPENAI_API_KEY=sk-... is labelled openai-key rather than env-secret.\\n# Each rule has its own replacement string so cookie/auth-header rules can preserve\\n# the surrounding header name and quoting.\\n$patterns = @(\\n @{ name = 'anthropic-key'; regex = 'sk-ant-[A-Za-z0-9_\\\\-]{20,}'; replacement = '[REDACTED:anthropic-key]' },\\n @{ name = 'openai-key'; regex = 'sk-(?!ant-)[A-Za-z0-9_\\\\-]{20,}'; replacement = '[REDACTED:openai-key]' },\\n @{ name = 'aws-access-key-id'; regex = '\\\\b(?:AKIA|ASIA)[A-Z0-9]{16}\\\\b'; replacement = '[REDACTED:aws-access-key-id]' },\\n @{ name = 'github-token'; regex = '\\\\b(?:gh[posru]_|github_pat_)[A-Za-z0-9_]{20,}\\\\b'; replacement = '[REDACTED:github-token]' },\\n @{ name = 'slack-token'; regex = 'xox[abprs]-[A-Za-z0-9\\\\-]{10,}'; replacement = '[REDACTED:slack-token]' },\\n @{ name = 'stripe-key'; regex = '\\\\b(?:sk|pk|rk)_live_[A-Za-z0-9]{20,}\\\\b'; replacement = '[REDACTED:stripe-key]' },\\n @{ name = 'google-api-key'; regex = '\\\\bAIza[A-Za-z0-9_\\\\-]{35}\\\\b'; replacement = '[REDACTED:google-api-key]' },\\n @{ name = 'jwt'; regex = '\\\\beyJ[A-Za-z0-9_\\\\-]{10,}\\\\.eyJ[A-Za-z0-9_\\\\-]{10,}\\\\.[A-Za-z0-9_\\\\-]{10,}\\\\b'; replacement = '[REDACTED:jwt]' },\\n @{ name = 'http-auth'; regex = '(?i)Authorization:\\\\s*(?:Basic|Bearer|Digest|Token|OAuth)\\\\s+[A-Za-z0-9+/=._\\\\-]{8,}'; replacement = 'Authorization: [REDACTED:http-auth]' },\\n @{ name = 'cookie-header'; regex = '(?i)(?:Cookie|Set-Cookie):\\\\s*[A-Za-z_][A-Za-z0-9_\\\\-]*=[^\\\"''\\\\\\\\\\\\r\\\\n]{10,}'; replacement = '[REDACTED:cookie-header]' },\\n @{ name = 'curl-cookie-arg'; regex = '(?<=\\\\s)(?:-b|--cookie)\\\\s+''[A-Za-z_][A-Za-z0-9_\\\\-]*=[^''\\\\\\\\\\\\r\\\\n]{10,}'''; replacement = \\\"-b '[REDACTED:cookie-header]'\\\" },\\n # Bare cookie chains (no `Cookie:` header in front) — 3+ name=value pairs separated by `; `.\\n # Catches pasted DevTools output, COOKIE=… shell vars, heredoc cookie files, etc.\\n # `(?/dev/null || echo unknown)\\n\\n# Session info shown in the shared-page header. Model and effort are live-session\\n# state only the running agent knows — BEFORE running, fill them from the current\\n# session (see \\\"Fill in the session info\\\" below); leave empty if unknown (the\\n# server falls back to the model parsed from the transcript). Plan is read from disk.\\nsession_model=\\\"\\\" # e.g. 'Opus 4.8 (1M context)'\\nsession_effort=\\\"\\\" # e.g. 'medium'\\nsession_plan=\\\"\\\"\\nif [ -f \\\"$HOME/.claude.json\\\" ]; then\\n org_type=$(python3 -c 'import json,sys; print((json.load(open(sys.argv[1])).get(\\\"oauthAccount\\\") or {}).get(\\\"organizationType\\\",\\\"\\\") or \\\"\\\")' \\\"$HOME/.claude.json\\\" 2>/dev/null || echo \\\"\\\")\\n case \\\"$org_type\\\" in\\n claude_max) session_plan=\\\"Claude Max\\\" ;;\\n claude_pro) session_plan=\\\"Claude Pro\\\" ;;\\n claude_team) session_plan=\\\"Claude Team\\\" ;;\\n claude_enterprise) session_plan=\\\"Claude Enterprise\\\" ;;\\n esac\\nfi\\nsession_headers=()\\n[ -n \\\"$session_model\\\" ] && session_headers+=(-H \\\"x-session-model: $session_model\\\")\\n[ -n \\\"$session_effort\\\" ] && session_headers+=(-H \\\"x-session-effort: $session_effort\\\")\\n[ -n \\\"$session_plan\\\" ] && session_headers+=(-H \\\"x-session-plan: $session_plan\\\")\\n\\n# Load the per-machine claim token if we have one. Server uses its hash to\\n# group every share from this device under a single identity so the user\\n# can later claim them all to an account.\\nclaim_token=\\\"\\\"\\nif [ -f \\\"$credentials_file\\\" ]; then\\n claim_token=$(python3 -c 'import json,sys; print(json.load(open(sys.argv[1])).get(\\\"claimToken\\\",\\\"\\\") or \\\"\\\")' \\\"$credentials_file\\\" 2>/dev/null || echo \\\"\\\")\\nfi\\n\\ncwd=\\\"$(pwd)\\\"\\nslug=$(echo \\\"$cwd\\\" | sed 's#/#-#g')\\nsrc=$(ls -t \\\"$HOME/.claude/projects/$slug\\\"/*.jsonl 2>/dev/null | head -1)\\n[ -z \\\"$src\\\" ] && { echo \\\"No session files in $HOME/.claude/projects/$slug\\\" >&2; exit 1; }\\nsidecar=\\\"$src.instashare.json\\\"\\ntmp=$(mktemp)\\nredacted=$(mktemp)\\nresp=\\\"\\\"\\n\\n# Redact common secrets before upload. Curated patterns only — provider-specific\\n# first so e.g. OPENAI_API_KEY=sk-... is labelled openai-key rather than env-secret.\\nsummary=$(python3 - \\\"$src\\\" \\\"$redacted\\\" <<'PY'\\nimport re, sys\\n# (regex, replacement). Provider-specific rules first so e.g. OPENAI_API_KEY=sk-...\\n# is labelled openai-key rather than env-secret. Cookie/auth-header rules keep\\n# their surrounding header name or curl flag intact.\\nPATTERNS = [\\n ('anthropic-key', r'sk-ant-[A-Za-z0-9_\\\\-]{20,}', '[REDACTED:anthropic-key]'),\\n ('openai-key', r'sk-(?!ant-)[A-Za-z0-9_\\\\-]{20,}', '[REDACTED:openai-key]'),\\n ('aws-access-key-id', r'\\\\b(?:AKIA|ASIA)[A-Z0-9]{16}\\\\b', '[REDACTED:aws-access-key-id]'),\\n ('github-token', r'\\\\b(?:gh[posru]_|github_pat_)[A-Za-z0-9_]{20,}\\\\b', '[REDACTED:github-token]'),\\n ('slack-token', r'xox[abprs]-[A-Za-z0-9\\\\-]{10,}', '[REDACTED:slack-token]'),\\n ('stripe-key', r'\\\\b(?:sk|pk|rk)_live_[A-Za-z0-9]{20,}\\\\b', '[REDACTED:stripe-key]'),\\n ('google-api-key', r'\\\\bAIza[A-Za-z0-9_\\\\-]{35}\\\\b', '[REDACTED:google-api-key]'),\\n ('jwt', r'\\\\beyJ[A-Za-z0-9_\\\\-]{10,}\\\\.eyJ[A-Za-z0-9_\\\\-]{10,}\\\\.[A-Za-z0-9_\\\\-]{10,}\\\\b', '[REDACTED:jwt]'),\\n ('http-auth', r'(?i)Authorization:\\\\s*(?:Basic|Bearer|Digest|Token|OAuth)\\\\s+[A-Za-z0-9+/=._\\\\-]{8,}', 'Authorization: [REDACTED:http-auth]'),\\n ('cookie-header', r'''(?i)(?:Cookie|Set-Cookie):\\\\s*[A-Za-z_][A-Za-z0-9_\\\\-]*=[^\\\"'\\\\\\\\\\\\r\\\\n]{10,}''', '[REDACTED:cookie-header]'),\\n ('curl-cookie-arg', r\\\"\\\"\\\"(?<=\\\\s)(?:-b|--cookie)\\\\s+'[A-Za-z_][A-Za-z0-9_\\\\-]*=[^'\\\\\\\\\\\\r\\\\n]{10,}'\\\"\\\"\\\", \\\"-b '[REDACTED:cookie-header]'\\\"),\\n # Bare cookie chains (no `Cookie:` header in front) — 3+ name=value pairs\\n # separated by `; `. Catches pasted DevTools output, COOKIE=… shell vars,\\n # heredoc cookie files, etc. `(?&2\\n rm -f \\\"$tmp\\\" \\\"$redacted\\\"\\n echo \\\"\\\" >&2\\n echo \\\"Upload failed (HTTP $code).\\\" >&2\\n exit 1\\n fi\\n resp=\\\"$(cat \\\"$tmp\\\")\\\"\\n # Save / refresh claim token. Always overwrite so server-side rotation works.\\n new_claim=$(echo \\\"$resp\\\" | python3 -c 'import json,sys; print(json.load(sys.stdin).get(\\\"claimToken\\\",\\\"\\\") or \\\"\\\")' 2>/dev/null || echo \\\"\\\")\\n if [ -n \\\"$new_claim\\\" ]; then\\n mkdir -p \\\"$credentials_dir\\\"\\n python3 -c 'import json,sys; json.dump({\\\"claimToken\\\": sys.argv[1]}, open(sys.argv[2],\\\"w\\\"))' \\\"$new_claim\\\" \\\"$credentials_file\\\"\\n chmod 600 \\\"$credentials_file\\\" 2>/dev/null || true\\n fi\\n echo \\\"$resp\\\" | python3 -c '\\nimport json, sys\\nd = json.load(sys.stdin)\\nurl = d.get(\\\"deleteUrl\\\", \\\"\\\")\\ntoken = url.split(\\\"token=\\\")[-1] if \\\"token=\\\" in url else \\\"\\\"\\nprint(json.dumps({\\\"slug\\\": d[\\\"slug\\\"], \\\"deleteToken\\\": token, \\\"url\\\": d[\\\"url\\\"]}))\\n' > \\\"$sidecar\\\"\\nfi\\nrm -f \\\"$tmp\\\" \\\"$redacted\\\"\\n\\necho \\\"$resp\\\" | python3 -c '\\nimport sys, json\\nd = json.load(sys.stdin)\\nprint(d[\\\"url\\\"])\\nprint(\\\"Delete:\\\", d[\\\"deleteUrl\\\"])\\nif not d.get(\\\"linked\\\") and d.get(\\\"claimUrl\\\"):\\n print(\\\"Make these yours:\\\", d[\\\"claimUrl\\\"])\\n'\\n[ -n \\\"$summary\\\" ] && echo \\\"Redacted before upload: $summary\\\"\\n```\\n\\nThe command prints the public URL on the first line and a delete URL on the second. Until the device has been claimed, a third line offers the **claim URL** that links every share from this device to a Google account. After claiming, that line disappears and shares show up immediately at `/mine`.\\n\\n## After the command runs\\n\\n1. **Report the public URL** to the user — one line, clickable.\\n2. **Show the delete URL** on a second line so they can revoke the share later. Opening it in a browser shows a confirmation page; nothing is removed until they click the \\\"Delete forever\\\" button. The token is one-shot per chat — if it's lost, the chat can't be deleted again.\\n3. **If the skill printed a `Make these yours:` line**, mention that opening it (and signing in with Google) attaches *every* share from this device — past and future — to a `/mine` page. This is optional; the public link works without it.\\n4. **Note what was redacted, if anything**: when a `Redacted before upload: …` line appears, the skill replaced matches of a curated pattern set (AWS / GitHub / Slack / Stripe / OpenAI / Anthropic / Google keys, JWTs, PEM private-key blocks, HTTP `Authorization: Basic|Bearer|…` headers, `Cookie:` / `Set-Cookie:` header values, curl `-b 'cookie=val; …'` flags, InstaShare's own delete/claim tokens from a previous run of this skill, and `*_KEY=` / `*_TOKEN=` / `*_SECRET=` / `*_PASSWORD=` assignments) with `[REDACTED:]` markers before upload. The scan is best-effort — custom or proprietary token formats won't match — so still suggest reviewing the public link if the chat may contain anything else sensitive.\\n\\n## How this works\\n\\n- **The mtime sort identifies the active session.** Claude Code writes to the most recently modified `.jsonl` in the project's slug directory, so a single `ls -t … | head -1` reliably picks it — no separate Glob/Read pre-flight needed.\\n- **The slug is the cwd with `/`, `\\\\`, `:` replaced by `-`, case preserved.** That matches the directory Claude Code creates, including any leading dash on macOS/Linux (`/Users/foo` → `-Users-foo`). Lowercasing it or stripping the leading dash will miss the directory on case-preserving filesystems.\\n- **The body is the file with common secrets scrubbed in place.** Before POST/PUT the snippet scans `$body` against a curated pattern set (provider API keys, JWTs, PEM private-key blocks, HTTP `Authorization` / `Cookie` / `Set-Cookie` header values, curl `-b 'cookies'` flags, InstaShare's own delete/claim tokens printed by a previous run, and `*_KEY=` / `*_TOKEN=` / `*_SECRET=` / `*_PASSWORD=` style env assignments) and replaces matches with `[REDACTED:]`. Everything else is uploaded verbatim. Secrets matching one of the patterns therefore never leave the machine — they're scrubbed before the HTTPS body is even constructed. The original `.jsonl` on disk is never modified.\\n- **The scan is best-effort.** It targets the well-known token formats listed above. Custom or proprietary tokens, free-form passwords in prose, and high-entropy strings without a recognizable prefix won't match. Still surface the public-link warning so the user can decide whether to share, and recommend reviewing the link if the chat may contain anything else sensitive.\\n- **Sidecar makes the URL stable across reruns.** After the first POST the script writes `.instashare.json` containing `{slug, deleteToken, url}`. On the next invocation it `PUT`s to `/api/chats/?token=`, which replaces the stored JSONL and recomputes stats while preserving the slug, created-at, and delete token. If the chat was deleted server-side (PUT returns 404) or the sidecar is stale/tampered (401/403), the script falls back to POST and overwrites the sidecar. Delete the sidecar manually to force a brand-new URL.\\n- **The claim token is per-machine, not per-share.** `~/.claude/instashare/credentials.json` is written on the first upload and reused thereafter. It's sent as `x-claim-token` on POST and PUT so the server can group all uploads from this device. If the server revokes it (the user clicked Revoke on `/account`), the next upload retries anonymously, the server mints a fresh token, and the user sees a fresh claim URL.\\n- **Session info is sent as headers, not baked into the body.** `x-session-model`, `x-session-effort`, and `x-session-plan` ride alongside the upload so the shared page can show e.g. `Opus 4.8 (1M context) with medium effort · Claude Max`. Plan comes from `~/.claude.json` (`oauthAccount.organizationType`); model/effort are filled in by the agent from the live session because the harness never writes them to the transcript (the persisted `message.model` is the bare id without the context-window marker, and effort isn't recorded at all). All three are optional — the server parses the base model from the transcript as a fallback, so a header-less or headless upload still shows the model.\\n- **The original session file is never modified.** Only the sidecar (a small JSON file next to the .jsonl) and the per-machine credentials file (`~/.claude/instashare/credentials.json`) are written locally; the .jsonl itself is read-only from the script's perspective.\\n\"}]},\"isMeta\":true,\"uuid\":\"996d86d9-cbb9-43b4-be1b-4ed5db97fcf6\",\"timestamp\":\"2026-06-16T18:25:50.941Z\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"c:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"parentUuid\":\"996d86d9-cbb9-43b4-be1b-4ed5db97fcf6\",\"isSidechain\":false,\"attachment\":{\"type\":\"command_permissions\",\"allowedTools\":[]},\"type\":\"attachment\",\"uuid\":\"a0396cf8-8527-4378-b55d-8289e36e3381\",\"timestamp\":\"2026-06-16T18:25:50.941Z\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"c:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"type\":\"file-history-snapshot\",\"messageId\":\"b399b670-cbea-402a-b560-a547d1dfe4c9\",\"snapshot\":{\"messageId\":\"b399b670-cbea-402a-b560-a547d1dfe4c9\",\"trackedFileBackups\":{\"C:\\\\Users\\\\smirn\\\\.claude\\\\projects\\\\c--Users-smirn-OneDrive-Documents-GitHub-botmakers-projects-copilot-us-instafill-ai\\\\memory\\\\MEMORY.md\":{\"backupFileName\":\"950615ce6d21e2e2@v2\",\"version\":2,\"backupTime\":\"2026-06-16T18:25:50.989Z\"},\"C:\\\\Users\\\\smirn\\\\.claude\\\\projects\\\\c--Users-smirn-OneDrive-Documents-GitHub-botmakers-projects-copilot-us-instafill-ai\\\\memory\\\\cms1500-insured-phone-field-fix.md\":{\"backupFileName\":\"e12be7b64923d118@v2\",\"version\":2,\"backupTime\":\"2026-06-16T18:25:50.990Z\"}},\"timestamp\":\"2026-06-16T18:25:50.990Z\"},\"isSnapshotUpdate\":false}\n{\"type\":\"last-prompt\",\"lastPrompt\":\"It is good now. save this corrected info and give me the link to download the filled form\",\"leafUuid\":\"a0396cf8-8527-4378-b55d-8289e36e3381\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\"}\n{\"type\":\"ai-title\",\"aiTitle\":\"View available workspace forms\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\"}\n{\"parentUuid\":\"a0396cf8-8527-4378-b55d-8289e36e3381\",\"isSidechain\":false,\"message\":{\"model\":\"claude-opus-4-8\",\"id\":\"msg_01Y97WBSsdVmsjn25yF2kQ5w\",\"type\":\"message\",\"role\":\"assistant\",\"content\":[{\"type\":\"thinking\",\"thinking\":\"\",\"signature\":\"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\"}],\"stop_reason\":\"tool_use\",\"stop_sequence\":null,\"stop_details\":null,\"usage\":{\"input_tokens\":1,\"cache_creation_input_tokens\":11677,\"cache_read_input_tokens\":62484,\"output_tokens\":3856,\"server_tool_use\":{\"web_search_requests\":0,\"web_fetch_requests\":0},\"service_tier\":\"standard\",\"cache_creation\":{\"ephemeral_1h_input_tokens\":11677,\"ephemeral_5m_input_tokens\":0},\"inference_geo\":\"not_available\",\"iterations\":[{\"input_tokens\":1,\"output_tokens\":3856,\"cache_read_input_tokens\":62484,\"cache_creation_input_tokens\":11677,\"cache_creation\":{\"ephemeral_5m_input_tokens\":0,\"ephemeral_1h_input_tokens\":11677},\"type\":\"message\"}],\"speed\":\"standard\"},\"diagnostics\":null},\"requestId\":\"req_011Cc7QfC3VG2YhLyd2iLUDp\",\"attributionSkill\":\"instashare\",\"type\":\"assistant\",\"uuid\":\"9f6f4d8a-fc89-4cc3-8de6-e4c9ad7ee2f9\",\"timestamp\":\"2026-06-16T18:25:55.611Z\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"c:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"parentUuid\":\"9f6f4d8a-fc89-4cc3-8de6-e4c9ad7ee2f9\",\"isSidechain\":false,\"message\":{\"model\":\"claude-opus-4-8\",\"id\":\"msg_01Y97WBSsdVmsjn25yF2kQ5w\",\"type\":\"message\",\"role\":\"assistant\",\"content\":[{\"type\":\"text\",\"text\":\"I'll upload this session to InstaShare. Running the Windows PowerShell script now with the session model filled in.\"}],\"stop_reason\":\"tool_use\",\"stop_sequence\":null,\"stop_details\":null,\"usage\":{\"input_tokens\":1,\"cache_creation_input_tokens\":11677,\"cache_read_input_tokens\":62484,\"output_tokens\":3856,\"server_tool_use\":{\"web_search_requests\":0,\"web_fetch_requests\":0},\"service_tier\":\"standard\",\"cache_creation\":{\"ephemeral_1h_input_tokens\":11677,\"ephemeral_5m_input_tokens\":0},\"inference_geo\":\"not_available\",\"iterations\":[{\"input_tokens\":1,\"output_tokens\":3856,\"cache_read_input_tokens\":62484,\"cache_creation_input_tokens\":11677,\"cache_creation\":{\"ephemeral_5m_input_tokens\":0,\"ephemeral_1h_input_tokens\":11677},\"type\":\"message\"}],\"speed\":\"standard\"},\"diagnostics\":null},\"requestId\":\"req_011Cc7QfC3VG2YhLyd2iLUDp\",\"attributionSkill\":\"instashare\",\"type\":\"assistant\",\"uuid\":\"bcb22a1a-592f-46cb-bc24-388c4cf84da2\",\"timestamp\":\"2026-06-16T18:25:56.089Z\",\"userType\":\"external\",\"entrypoint\":\"claude-vscode\",\"cwd\":\"c:\\\\Users\\\\smirn\\\\OneDrive\\\\Documents\\\\GitHub\\\\botmakers\\\\projects\\\\copilot-us\\\\instafill.ai\",\"sessionId\":\"986638d6-b238-4e02-83a0-449ec3df5830\",\"version\":\"2.1.178\",\"gitBranch\":\"dev\"}\n{\"parentUuid\":\"bcb22a1a-592f-46cb-bc24-388c4cf84da2\",\"isSidechain\":false,\"message\":{\"model\":\"claude-opus-4-8\",\"id\":\"msg_01Y97WBSsdVmsjn25yF2kQ5w\",\"type\":\"message\",\"role\":\"assistant\",\"content\":[{\"type\":\"tool_use\",\"id\":\"toolu_01GCPm1ygEMi495xpDV2Mix6\",\"name\":\"PowerShell\",\"input\":{\"command\":\"$apiBase = if ($env:INSTASHARE_API_URL) { $env:INSTASHARE_API_URL } else { 'https://instashare.to' }\\n$credentialsDir = Join-Path $env:USERPROFILE \\\".claude\\\\instashare\\\"\\n$credentialsFile = Join-Path $credentialsDir \\\"credentials.json\\\"\\n$deviceHostname = $env:COMPUTERNAME\\n\\n$sessionModel = 'Opus 4.8 (1M context)'\\n$sessionEffort = ''\\n$sessionPlan = ''\\n$claudeConfig = Join-Path $env:USERPROFILE \\\".claude.json\\\"\\nif (Test-Path $claudeConfig) {\\n try {\\n $orgType = (Get-Content $claudeConfig -Raw -Encoding UTF8 | ConvertFrom-Json).oauthAccount.organizationType\\n switch ($orgType) {\\n 'claude_max' { $sessionPlan = 'Claude Max' }\\n 'claude_pro' { $sessionPlan = 'Claude Pro' }\\n 'claude_team' { $sessionPlan = 'Claude Team' }\\n 'claude_enterprise' { $sessionPlan = 'Claude Enterprise' }\\n }\\n } catch { }\\n}\\n\\n$claimToken = $null\\nif (Test-Path $credentialsFile) {\\n try {\\n $claimToken = (Get-Content $credentialsFile -Raw -Encoding UTF8 | ConvertFrom-Json).claimToken\\n } catch { }\\n}\\n\\n$cwd = (Get-Location).Path\\n$slug = $cwd.Replace(':', '-').Replace('\\\\', '-')\\n$projDir = Join-Path $env:USERPROFILE \\\".claude\\\\projects\\\\$slug\\\"\\n$src = Get-ChildItem \\\"$projDir\\\\*.jsonl\\\" -ErrorAction Stop |\\n Sort-Object LastWriteTime -Descending | Select-Object -First 1\\n$body = Get-Content $src.FullName -Raw -Encoding UTF8\\n$sidecar = \\\"$($src.FullName).instashare.json\\\"\\n\\n$patterns = @(\\n @{ name = 'anthropic-key'; regex = 'sk-ant-[A-Za-z0-9_\\\\-]{20,}'; replacement = '[REDACTED:anthropic-key]' },\\n @{ name = 'openai-key'; regex = 'sk-(?!ant-)[A-Za-z0-9_\\\\-]{20,}'; replacement = '[REDACTED:openai-key]' },\\n @{ name = 'aws-access-key-id'; regex = '\\\\b(?:AKIA|ASIA)[A-Z0-9]{16}\\\\b'; replacement = '[REDACTED:aws-access-key-id]' },\\n @{ name = 'github-token'; regex = '\\\\b(?:gh[posru]_|github_pat_)[A-Za-z0-9_]{20,}\\\\b'; replacement = '[REDACTED:github-token]' },\\n @{ name = 'slack-token'; regex = 'xox[abprs]-[A-Za-z0-9\\\\-]{10,}'; replacement = '[REDACTED:slack-token]' },\\n @{ name = 'stripe-key'; regex = '\\\\b(?:sk|pk|rk)_live_[A-Za-z0-9]{20,}\\\\b'; replacement = '[REDACTED:stripe-key]' },\\n @{ name = 'google-api-key'; regex = '\\\\bAIza[A-Za-z0-9_\\\\-]{35}\\\\b'; replacement = '[REDACTED:google-api-key]' },\\n @{ name = 'jwt'; regex = '\\\\beyJ[A-Za-z0-9_\\\\-]{10,}\\\\.eyJ[A-Za-z0-9_\\\\-]{10,}\\\\.[A-Za-z0-9_\\\\-]{10,}\\\\b'; replacement = '[REDACTED:jwt]' },\\n @{ name = 'http-auth'; regex = '(?i)Authorization:\\\\s*(?:Basic|Bearer|Digest|Token|OAuth)\\\\s+[A-Za-z0-9+/=._\\\\-]{8,}'; replacement = 'Authorization: [REDACTED:http-auth]' },\\n @{ name = 'cookie-header'; regex = '(?i)(?:Cookie|Set-Cookie):\\\\s*[A-Za-z_][A-Za-z0-9_\\\\-]*=[^\\\"''\\\\\\\\\\\\r\\\\n]{10,}'; replacement = '[REDACTED:cookie-header]' },\\n @{ name = 'curl-cookie-arg'; regex = '(?<=\\\\s)(?:-b|--cookie)\\\\s+''[A-Za-z_][A-Za-z0-9_\\\\-]*=[^''\\\\\\\\\\\\r\\\\n]{10,}'''; replacement = \\\"-b '[REDACTED:cookie-header]'\\\" },\\n @{ name = 'cookie-chain'; regex = '(?