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+ "text": "NJ",
455
+ "label": "Other"
456
+ },
457
+ {
458
+ "box": [
459
+ 61.694117647058825,
460
+ 23.01818181818182,
461
+ 73.10588235294118,
462
+ 24.381818181818183
463
+ ],
464
+ "text": "WILLINGBORO",
465
+ "label": "Other"
466
+ },
467
+ {
468
+ "box": [
469
+ 89.81176470588235,
470
+ 23.01818181818182,
471
+ 92.25882352941177,
472
+ 24.272727272727273
473
+ ],
474
+ "text": "NJ",
475
+ "label": "Other"
476
+ },
477
+ {
478
+ "box": [
479
+ 4.352941176470588,
480
+ 24.69090909090909,
481
+ 9.36470588235294,
482
+ 25.727272727272727
483
+ ],
484
+ "text": "ZIP CODE",
485
+ "label": "Other"
486
+ },
487
+ {
488
+ "box": [
489
+ 19.83529411764706,
490
+ 24.69090909090909,
491
+ 34.635294117647064,
492
+ 25.727272727272727
493
+ ],
494
+ "text": "TELEPHONE (Include Area Code)",
495
+ "label": "Other"
496
+ },
497
+ {
498
+ "box": [
499
+ 61.694117647058825,
500
+ 24.69090909090909,
501
+ 66.70588235294117,
502
+ 25.727272727272727
503
+ ],
504
+ "text": "ZIP CODE",
505
+ "label": "Other"
506
+ },
507
+ {
508
+ "box": [
509
+ 77.17647058823529,
510
+ 24.69090909090909,
511
+ 92.25882352941176,
512
+ 25.727272727272727
513
+ ],
514
+ "text": "TELEPHONE (Include Area Code)",
515
+ "label": "Other"
516
+ },
517
+ {
518
+ "box": [
519
+ 78.68235294117648,
520
+ 26.145454545454545,
521
+ 92.91764705882353,
522
+ 27.618181818181817
523
+ ],
524
+ "text": "(973)424 3625",
525
+ "label": "Other"
526
+ },
527
+ {
528
+ "box": [
529
+ 4.4941176470588236,
530
+ 26.345454545454544,
531
+ 14.4,
532
+ 27.49090909090909
533
+ ],
534
+ "text": "08046 3512",
535
+ "label": "Other"
536
+ },
537
+ {
538
+ "box": [
539
+ 61.95294117647059,
540
+ 26.254545454545454,
541
+ 72.0,
542
+ 27.4
543
+ ],
544
+ "text": "08046 3512",
545
+ "label": "Other"
546
+ },
547
+ {
548
+ "box": [
549
+ 4.211764705882353,
550
+ 27.6,
551
+ 35.05882352941177,
552
+ 28.963636363636365
553
+ ],
554
+ "text": "9.OTHER INSURED'S NAME (Last Name, First Name, Middle Initial)",
555
+ "label": "Other"
556
+ },
557
+ {
558
+ "box": [
559
+ 37.90588235294118,
560
+ 27.70909090909091,
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+ 58.423529411764704,
562
+ 28.745454545454546
563
+ ],
564
+ "text": "10.IS PATIENT'S CONDITION RELATED TO",
565
+ "label": "Other"
566
+ },
567
+ {
568
+ "box": [
569
+ 61.694117647058825,
570
+ 27.70909090909091,
571
+ 85.85882352941177,
572
+ 28.745454545454546
573
+ ],
574
+ "text": "11.INSURED'S POLICY GROUP OR FECA NUMBER",
575
+ "label": "Other"
576
+ },
577
+ {
578
+ "box": [
579
+ 61.811764705882354,
580
+ 29.054545454545455,
581
+ 66.02352941176471,
582
+ 30.2
583
+ ],
584
+ "text": "NONE",
585
+ "label": "Other"
586
+ },
587
+ {
588
+ "box": [
589
+ 61.55294117647059,
590
+ 30.418181818181818,
591
+ 76.21176470588236,
592
+ 31.763636363636362
593
+ ],
594
+ "text": "a.INSURED'S DATE OF BIRTH",
595
+ "label": "Other"
596
+ },
597
+ {
598
+ "box": [
599
+ 85.74117647058823,
600
+ 30.527272727272727,
601
+ 88.30588235294117,
602
+ 31.672727272727272
603
+ ],
604
+ "text": "SEX",
605
+ "label": "Other"
606
+ },
607
+ {
608
+ "box": [
609
+ 4.352941176470588,
610
+ 30.836363636363636,
611
+ 28.799999999999997,
612
+ 31.87272727272727
613
+ ],
614
+ "text": "a.OTHER INSURED'S POLICY OR GROUP NUMBER",
615
+ "label": "Other"
616
+ },
617
+ {
618
+ "box": [
619
+ 38.04705882352941,
620
+ 30.836363636363636,
621
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622
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623
+ ],
624
+ "text": "a.EMPLOYMENT?(CURRENT OR PREVIOUS)",
625
+ "label": "Other"
626
+ },
627
+ {
628
+ "box": [
629
+ 43.48235294117647,
630
+ 32.09090909090909,
631
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632
+ 33.654545454545456
633
+ ],
634
+ "text": "[YES",
635
+ "label": "Other"
636
+ },
637
+ {
638
+ "box": [
639
+ 89.81176470588235,
640
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641
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642
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643
+ ],
644
+ "text": "FX",
645
+ "label": "Other"
646
+ },
647
+ {
648
+ "box": [
649
+ 50.63529411764706,
650
+ 31.945454545454545,
651
+ 54.65882352941176,
652
+ 33.2
653
+ ],
654
+ "text": "NO",
655
+ "label": "Other"
656
+ },
657
+ {
658
+ "box": [
659
+ 66.02352941176471,
660
+ 32.18181818181818,
661
+ 77.31764705882354,
662
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663
+ ],
664
+ "text": "01071967",
665
+ "label": "Other"
666
+ },
667
+ {
668
+ "box": [
669
+ 81.24705882352941,
670
+ 32.18181818181818,
671
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672
+ 33.43636363636364
673
+ ],
674
+ "text": "M",
675
+ "label": "Other"
676
+ },
677
+ {
678
+ "box": [
679
+ 37.90588235294118,
680
+ 33.654545454545456,
681
+ 47.95294117647059,
682
+ 34.690909090909095
683
+ ],
684
+ "text": "b.AUTO ACCIDENT?",
685
+ "label": "Other"
686
+ },
687
+ {
688
+ "box": [
689
+ 53.95294117647059,
690
+ 33.654545454545456,
691
+ 60.705882352941174,
692
+ 34.800000000000004
693
+ ],
694
+ "text": "PLACE (State)",
695
+ "label": "Other"
696
+ },
697
+ {
698
+ "box": [
699
+ 4.352941176470588,
700
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701
+ 18.894117647058824,
702
+ 34.8
703
+ ],
704
+ "text": "b.RESERVED FOR NUCC USE",
705
+ "label": "Other"
706
+ },
707
+ {
708
+ "box": [
709
+ 61.55294117647059,
710
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711
+ 81.10588235294118,
712
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713
+ ],
714
+ "text": "b.OTHER CLAIM ID (Designated by NUCC)",
715
+ "label": "Other"
716
+ },
717
+ {
718
+ "box": [
719
+ 43.48235294117647,
720
+ 35.10909090909091,
721
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722
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723
+ ],
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+ "text": " YeS",
725
+ "label": "Other"
726
+ },
727
+ {
728
+ "box": [
729
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730
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731
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732
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733
+ ],
734
+ "text": "XNO",
735
+ "label": "Other"
736
+ },
737
+ {
738
+ "box": [
739
+ 4.211764705882353,
740
+ 36.56363636363636,
741
+ 18.75294117647059,
742
+ 37.6
743
+ ],
744
+ "text": "c.RESERVED FOR NUCC USE",
745
+ "label": "Other"
746
+ },
747
+ {
748
+ "box": [
749
+ 38.188235294117646,
750
+ 36.872727272727275,
751
+ 48.23529411764706,
752
+ 37.909090909090914
753
+ ],
754
+ "text": "C.OTHER ACCIDENT?",
755
+ "label": "Other"
756
+ },
757
+ {
758
+ "box": [
759
+ 61.694117647058825,
760
+ 36.872727272727275,
761
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762
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763
+ ],
764
+ "text": "C.INSURANCE PLAN NAME OR PROGRAM NAME",
765
+ "label": "Other"
766
+ },
767
+ {
768
+ "box": [
769
+ 43.48235294117647,
770
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771
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772
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773
+ ],
774
+ "text": "[YES",
775
+ "label": "Other"
776
+ },
777
+ {
778
+ "box": [
779
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780
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781
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782
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783
+ ],
784
+ "text": "NO",
785
+ "label": "Other"
786
+ },
787
+ {
788
+ "box": [
789
+ 38.04705882352941,
790
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791
+ 57.34117647058824,
792
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793
+ ],
794
+ "text": "10d.CLAIM CODES(Designated by NUCC)",
795
+ "label": "Other"
796
+ },
797
+ {
798
+ "box": [
799
+ 61.811764705882354,
800
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801
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802
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803
+ ],
804
+ "text": "d.IS THERE ANOTHER HEALTH BENEFIT PLAN?",
805
+ "label": "Other"
806
+ },
807
+ {
808
+ "box": [
809
+ 63.576470588235296,
810
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811
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812
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813
+ ],
814
+ "text": "YESXNO",
815
+ "label": "Other"
816
+ },
817
+ {
818
+ "box": [
819
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820
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821
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822
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823
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824
+ "text": "If yes complete items 9,9a,and 9d",
825
+ "label": "Other"
826
+ },
827
+ {
828
+ "box": [
829
+ 15.764705882352942,
830
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831
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832
+ 43.85454545454546
833
+ ],
834
+ "text": "READ BACK OF FORM BEFORE COMPLETING & SIGNING THIS FORM.",
835
+ "label": "Other"
836
+ },
837
+ {
838
+ "box": [
839
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840
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841
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842
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843
+ ],
844
+ "text": "13.INSURED'S OR AUTHORIZED PERSON'S SIGNATURE I authorize",
845
+ "label": "Other"
846
+ },
847
+ {
848
+ "box": [
849
+ 4.6117647058823525,
850
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851
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852
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853
+ ],
854
+ "text": "12.PATIENT'S OR AUTHORIZEDPERSON'S SIGNATURE I authorize the release of any medical or other information necessar",
855
+ "label": "Other"
856
+ },
857
+ {
858
+ "box": [
859
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860
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861
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862
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863
+ ],
864
+ "text": "enefits to the undersigned physician or supplier for",
865
+ "label": "Other"
866
+ },
867
+ {
868
+ "box": [
869
+ 61.811764705882354,
870
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871
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872
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873
+ ],
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+ "text": "service described below.",
875
+ "label": "Other"
876
+ },
877
+ {
878
+ "box": [
879
+ 5.976470588235294,
880
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881
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882
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883
+ ],
884
+ "text": "to process this claim.I also request payment of government benefits either to myself or to the party who accepts assignment",
885
+ "label": "Other"
886
+ },
887
+ {
888
+ "box": [
889
+ 5.976470588235294,
890
+ 45.61818181818182,
891
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892
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893
+ ],
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+ "text": "below.",
895
+ "label": "Other"
896
+ },
897
+ {
898
+ "box": [
899
+ 9.647058823529411,
900
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901
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902
+ 50.0
903
+ ],
904
+ "text": "F_CURRENT ILLNESS, INJURY,or PREGNANCY (LMP)",
905
+ "label": "Other"
906
+ },
907
+ {
908
+ "box": [
909
+ 35.2,
910
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911
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912
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913
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914
+ "text": "15.OTHERDATE",
915
+ "label": "Other"
916
+ },
917
+ {
918
+ "box": [
919
+ 61.694117647058825,
920
+ 48.96363636363636,
921
+ 93.62352941176471,
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+ 50.0
923
+ ],
924
+ "text": "16.DATESPATIENT UNABLE TO WORK IN CURRENT OCCUPATION",
925
+ "label": "Other"
926
+ },
927
+ {
928
+ "box": [
929
+ 4.6117647058823525,
930
+ 49.163636363636364,
931
+ 9.36470588235294,
932
+ 49.89090909090909
933
+ ],
934
+ "text": "14.DATEC",
935
+ "label": "Other"
936
+ },
937
+ {
938
+ "box": [
939
+ 46.72941176470588,
940
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941
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942
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943
+ ],
944
+ "text": "MM",
945
+ "label": "Other"
946
+ },
947
+ {
948
+ "box": [
949
+ 49.71764705882353,
950
+ 49.8,
951
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952
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953
+ ],
954
+ "text": "DD",
955
+ "label": "Other"
956
+ },
957
+ {
958
+ "box": [
959
+ 52.44705882352941,
960
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961
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962
+ 50.61818181818182
963
+ ],
964
+ "text": "IYY",
965
+ "label": "Other"
966
+ },
967
+ {
968
+ "box": [
969
+ 11.811764705882354,
970
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971
+ 16.447058823529414,
972
+ 51.763636363636365
973
+ ],
974
+ "text": "2022",
975
+ "label": "Other"
976
+ },
977
+ {
978
+ "box": [
979
+ 17.08235294117647,
980
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981
+ 24.49411764705882,
982
+ 51.54545454545455
983
+ ],
984
+ "text": "QUAL.431",
985
+ "label": "Other"
986
+ },
987
+ {
988
+ "box": [
989
+ 35.6,
990
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991
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992
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993
+ ],
994
+ "text": "QUAL.",
995
+ "label": "Other"
996
+ },
997
+ {
998
+ "box": [
999
+ 5.7176470588235295,
1000
+ 50.61818181818182,
1001
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1002
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1003
+ ],
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+ "text": "06",
1005
+ "label": "Other"
1006
+ },
1007
+ {
1008
+ "box": [
1009
+ 9.105882352941176,
1010
+ 50.61818181818182,
1011
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1012
+ 51.45454545454545
1013
+ ],
1014
+ "text": "29",
1015
+ "label": "Other"
1016
+ },
1017
+ {
1018
+ "box": [
1019
+ 63.45882352941177,
1020
+ 50.72727272727273,
1021
+ 66.56470588235294,
1022
+ 51.56363636363636
1023
+ ],
1024
+ "text": "FROM",
1025
+ "label": "Other"
1026
+ },
1027
+ {
1028
+ "box": [
1029
+ 80.84705882352941,
1030
+ 50.72727272727273,
1031
+ 82.47058823529412,
1032
+ 51.56363636363636
1033
+ ],
1034
+ "text": "TO",
1035
+ "label": "Other"
1036
+ },
1037
+ {
1038
+ "box": [
1039
+ 4.211764705882353,
1040
+ 51.872727272727275,
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+ 32.32941176470588,
1042
+ 52.92727272727273
1043
+ ],
1044
+ "text": "17.NAME OF REFERRING PHYSICIAN OR OTHER SOURCE",
1045
+ "label": "Other"
1046
+ },
1047
+ {
1048
+ "box": [
1049
+ 36.141176470588235,
1050
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1051
+ 37.90588235294118,
1052
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1053
+ ],
1054
+ "text": "17a.",
1055
+ "label": "Other"
1056
+ },
1057
+ {
1058
+ "box": [
1059
+ 90.63529411764706,
1060
+ 52.81818181818182,
1061
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1062
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1063
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1064
+ "text": "YY",
1065
+ "label": "Other"
1066
+ },
1067
+ {
1068
+ "box": [
1069
+ 4.4941176470588236,
1070
+ 53.54545454545455,
1071
+ 18.894117647058824,
1072
+ 54.581818181818186
1073
+ ],
1074
+ "text": "DN MARK REKANT",
1075
+ "label": "Other"
1076
+ },
1077
+ {
1078
+ "box": [
1079
+ 35.45882352941177,
1080
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+ 50.682352941176475,
1082
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1083
+ ],
1084
+ "text": "17b.NP1457388050",
1085
+ "label": "Other"
1086
+ },
1087
+ {
1088
+ "box": [
1089
+ 63.576470588235296,
1090
+ 53.654545454545456,
1091
+ 66.44705882352942,
1092
+ 54.472727272727276
1093
+ ],
1094
+ "text": "FROM",
1095
+ "label": "Other"
1096
+ },
1097
+ {
1098
+ "box": [
1099
+ 80.84705882352941,
1100
+ 53.54545454545455,
1101
+ 82.47058823529412,
1102
+ 54.472727272727276
1103
+ ],
1104
+ "text": "TO",
1105
+ "label": "Other"
1106
+ },
1107
+ {
1108
+ "box": [
1109
+ 4.352941176470588,
1110
+ 54.8,
1111
+ 32.87058823529412,
1112
+ 55.836363636363636
1113
+ ],
1114
+ "text": "19.ADDITIONAL CLAIM INFORMATION (Designated by NUCC)",
1115
+ "label": "Other"
1116
+ },
1117
+ {
1118
+ "box": [
1119
+ 61.694117647058825,
1120
+ 54.89090909090909,
1121
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1128
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1129
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1148
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1149
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1158
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1159
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1168
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1169
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+ "text": "A.M25 631",
1185
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1186
+ },
1187
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1188
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1189
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1190
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1191
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1195
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1196
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1197
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1198
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1199
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1200
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1206
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1208
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1209
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1228
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1229
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1238
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1239
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1268
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1300
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1778
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1798
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1808
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1858
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1868
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1869
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1888
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1889
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1898
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1899
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1908
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1915
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1917
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1918
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1919
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1928
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1938
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1939
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1948
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1949
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1958
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1968
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1978
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1979
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1988
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1989
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1993
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+ "text": "NPI",
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+ "label": "Other"
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1998
+ "box": [
1999
+ 22,
2000
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2001
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2002
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2005
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2008
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2009
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2010
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2012
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+ "label": "Other"
2016
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2017
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2018
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2019
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2020
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2028
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2038
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2048
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2058
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2059
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+ "label": "Other"
2066
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2068
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2069
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2075
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2078
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2088
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2098
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2108
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2148
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2178
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2179
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2189
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2318
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