Medical Order Edit, Document

Date of Current	The date of the current illness, injury or accident.
Type	Illness, to indicate illness. Accident, to indicate accident. Pregnancy, to indicate pregnancy.
Date of Similar Illness	The first date patient had the same or a similar illness.
Dates unable to work in current occupation	The date range the patient has not been able to work in their current occupation.
Referring Physician	The name and NPI of the physician that ordered the equipment or referred the patient.
Hospitalization related to services	The dates the patient was hospitalized related to the current services.
Reserved for Local Use 19	Enter text to fill in Box 19 on CMS-1500 form
Outside Lab	Yes, if there is an outside lab charge on this claim. No, otherwise.
Charges	The amount of outside lab charges.
Reserved for Local Use 10d	Enter text to fill in Box 10d on CMS-1500 form
Hold Reason	The reason you want this Order held. As long as there is something here, the Order/Claim will not be submitted.
22. Resubmission Code	Enter text to fill in Box 22 on CMS-1500 form
Original Reference	Enter text to fill in Box 22b on CMS-1500 form
Narrative	Enter the text which you would like to attach to the Order to go as the Narrative.Note: Narrative is limited to 80 characters by the ANSI 4010 format. You can have only one per Order, and one on each Line Item.
Paperwork Attachment	select the paperwork and type that will be attached to this order.