Required Client Demographic Information

• Client LME Affiliation (Example: Foothills, Neuse, Wake, Etc.)
• Client LME Medical Record Number
• Client Provider Medical Record Number
• Client First, Middle, Maiden & Last Name
• Client Date of Birth
• Gender (Male/Female)
• Client Street Address
• Client City , State & Zip Code
• Client Diagnosis Information
• Primary Diagnosis 1
• Primary Diagnosis 2
• Primary Diagnosis 3
• Primary Diagnosis 4
• Start/End Date of Above Diagnosis
• Client Funding Sources
  • Medicaid
  • Medicare
  • IPRS
  • Primary Insurance
• Client Funding Source Information (Information required for each funding source)
  • Client Eligibility Identification Number
  • Funding Source Effective/Lapse Dates
  • Funding Source Plan Name

  (Examples: Medicaid, Medicare, Blue Cross, CIGNA, etc.)

• Funding Source Policy Holder Information
  • First, Middle Initial & Last Name
  • Street Address, City, State & Zip Code
  • Telephone Number including Area Code
  • Policyholder Relation to Client
  • Policyholder Date of Birth
  • Policyholder Gender

Required Staff/Attending Provider Information

• Staff/Attending Provider Status (Profit/Non-Profit)
• Staff/Attending Provider Last Name
• Staff/Attending Provider First Name
• Staff/Attending Provider Middle Name
• Staff/Attending Provider Maiden Name
• Staff/Attending Provider Credentials (if applicable)
• Staff/Attending Provider Location/Facility
• Staff/Attending Provider Location/Facility Street Address
• Staff/Attending Provider Location/Facility City, State & Zip Code
• Federal ID#
• Staff/Attending Provider Billing Number
• Staff/Attending Provider IPRS Enrollment Number
• Endorsed Provider (Yes/No)
• Provisional Endorsement (Yes/No)
• Endorsement Effective/Lapse Dates
• Endorsed Services