Specifications include, but are not limited to: 1 CardholderID_302_C2 Cardholder ID 302-C2 20 Text Medicare ID or New Medicare Beneficary ID(MBI) 2 SSN - - 9 Text Social Security Number (will be optional and CMS may require that we do not keep the patient's SSN, after the complete roll out of the MBI, by CMS/Medicare) 3 DateofBirth_304_C4 Date of Birth 304-C4 8 Text Format=CCYYMMDD CC=Century YY=Year MM=Month DD=Day Examples: If a patient was born on July 27, 197Ø, this field would reflect: 197ØØ727 4 PatientGenderCode_305_C5 Patient Gender Code 305-C5 1 Text 1=Male; 2=Female 5 PatientFirstName_310_CA Patient First Name 310-CA 12 Text Patient First Name 6 PatientLastName_311_CB Patient Last Name 311-CB 15 Text Patient Last Name 7 CardholderFirstName_312_CC CardholderFirstName 312-CC 12 Text Cardholder First Name 8 CardholderLastName_313_CD CardholderLastName 313-CD 15 Text Cardholder Last Name 9 PatientStreetAddress_322_CM Patient Street Address 322-CM 30 Text Street Address 10 PatientCityAddress_323_CN Patient City Address 323-CN 20 Text Address City 11 PatientState_ProvinceAddress_324_CO Patient State/Province Address 324-CO 2 Text Address State 12 PatientZip_PostalZone_325_CP Patient Zip/Postal Zone 325-CP 15 Text Address Zipcode 13 PatientPhoneNumber_326_CQ Patient Phone Number 326-CQ 10 Text Phone number -No Dashes. 14 AlternateId_330_CW Alternate ID 33Ø-CW 20 Text Person identifier to be used for controlled product reporting. Identifier may be that of the patient or the person picking up the prescription as required by the governing body. 15 FacilityID_336_8C Facility ID 336-8C 10 Text ID assigned to the patient’s clinic/host party.
