- Review the information and make changes as needed per the community’s policy. Several fields below will also print out on the Face Sheet report, such as primary insurance, secondary insurance, and responsible party.
Primary Insurance
Primary Insurance Name
Primary Insurance Billing Address
Primary Insurance Phone Number
Secondary Insurance
Secondary Insurance Name
Secondary Insurance Billing Address
Secondary Insurance Phone Number
Tertiary Insurance
Tertiary Insurance Name
Tertiary Insurance Billing Address
Tertiary Insurance Phone Number
Source of Reimbursement
Responsible Party
Responsible Party Name
Responsible Party Phone Number
Financial Power of Attorney
Financial Power of Attorney Name
Financial Power of Attorney Phone
If changes are made, select Save at the bottom of the screen.
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