{
  "categories": [
    {
      "id": 0,
      "name": "10. IS PATIENT\u2019S CONDITION RELATED TO:"
    },
    {
      "id": 1,
      "name": "10D_Claim_Codes"
    },
    {
      "id": 2,
      "name": "11. INSURED\u2019S POLICY GROUP OR FECA NUMBER"
    },
    {
      "id": 3,
      "name": "11. d. IS THERE ANOTHER HEALTH BENEFIT PLAN?"
    },
    {
      "id": 4,
      "name": "11A_Ins_DOB"
    },
    {
      "id": 5,
      "name": "11B_Other_Claim_Id"
    },
    {
      "id": 6,
      "name": "11C_Ins_Plan_Name"
    },
    {
      "id": 7,
      "name": "12_Patient_Auth_Sign"
    },
    {
      "id": 8,
      "name": "13. INSURED\u2019S OR AUTHORIZED PERSON\u2019S SIGNATURE"
    },
    {
      "id": 9,
      "name": "14. DATE OF CURRENT"
    },
    {
      "id": 10,
      "name": "15_Other_Date"
    },
    {
      "id": 11,
      "name": "16_Date"
    },
    {
      "id": 12,
      "name": "17. NAME OF REFERRING PHYSICIAN OR OTHER SOURCE"
    },
    {
      "id": 13,
      "name": "17a. Qual"
    },
    {
      "id": 14,
      "name": "17b. NPI"
    },
    {
      "id": 15,
      "name": "19. Additional Claim Information"
    },
    {
      "id": 16,
      "name": "19_Hospitalization_Date"
    },
    {
      "id": 17,
      "name": "1_InsType"
    },
    {
      "id": 18,
      "name": "1a. INSURED\u2019S I.D. NUMBER"
    },
    {
      "id": 19,
      "name": "2. PATIENT\u2019S NAME (Last Name, First Name, Middle Initial)"
    },
    {
      "id": 20,
      "name": "20_Outside_Lab"
    },
    {
      "id": 21,
      "name": "21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY."
    },
    {
      "id": 22,
      "name": "22. MEDICAID RESUBMISSION CODE and Original Ref No"
    },
    {
      "id": 23,
      "name": "23. PRIOR AUTHORIZATION NUMBER"
    },
    {
      "id": 24,
      "name": "24. Table"
    },
    {
      "id": 25,
      "name": "25. FEDERAL TAX I.D. NUMBER_SSN_EIN"
    },
    {
      "id": 26,
      "name": "26. PATIENT\u2019S ACCOUNT NO."
    },
    {
      "id": 27,
      "name": "27. ACCEPT ASSIGNMENT?"
    },
    {
      "id": 28,
      "name": "28. TOTAL CHARGE"
    },
    {
      "id": 29,
      "name": "29. AMOUNT PAID"
    },
    {
      "id": 30,
      "name": "3. PATIENT\u2019S BIRTH DATE"
    },
    {
      "id": 31,
      "name": "30_Reserved_NUCC"
    },
    {
      "id": 32,
      "name": "31. SIGNATURE OF PHYSICIAN OR SUPPLIER  INCLUDING DEGREES OR CREDENTIALS"
    },
    {
      "id": 33,
      "name": "32. SERVICE FACILITY LOCATION INFORMATION"
    },
    {
      "id": 34,
      "name": "32A_NPI_Code"
    },
    {
      "id": 35,
      "name": "32B_Code"
    },
    {
      "id": 36,
      "name": "33. PHYSICIAN\u2019S, SUPPLIER\u2019S BILLING NAME, ADDRESS"
    },
    {
      "id": 37,
      "name": "33. PHYSICIAN\u2019S, SUPPLIER\u2019S FullID"
    },
    {
      "id": 38,
      "name": "33. PHYSICIAN\u2019S, SUPPLIER\u2019S NPI"
    },
    {
      "id": 39,
      "name": "4. INSURED\u2019S NAME (Last Name, First Name, Middle Initial)"
    },
    {
      "id": 40,
      "name": "5. PATIENT\u2019S ADDRESS (No., Street)"
    },
    {
      "id": 41,
      "name": "5. Pat_CITY"
    },
    {
      "id": 42,
      "name": "5. Pat_STATE"
    },
    {
      "id": 43,
      "name": "5. Pat_ZIP CODE"
    },
    {
      "id": 44,
      "name": "5_Telephone"
    },
    {
      "id": 45,
      "name": "6. PATIENT RELATIONSHIP TO INSURED"
    },
    {
      "id": 46,
      "name": "7. INSURED\u2019S ADDRESS (No., Street)"
    },
    {
      "id": 47,
      "name": "7. Insurer_CITY"
    },
    {
      "id": 48,
      "name": "7. Insurer_STATE"
    },
    {
      "id": 49,
      "name": "7. Insurer_ZIP CODE"
    },
    {
      "id": 50,
      "name": "7_Telephone"
    },
    {
      "id": 51,
      "name": "8_Reserved_NUCC"
    },
    {
      "id": 52,
      "name": "9. a. OTHER INSURED\u2019S POLICY OR GROUP NUMBER"
    },
    {
      "id": 53,
      "name": "9. d. INSURANCE PLAN NAME OR PROGRAM NAME"
    },
    {
      "id": 54,
      "name": "9B_Reserved_NUCC"
    },
    {
      "id": 55,
      "name": "9C_Reserved_NUCC"
    },
    {
      "id": 56,
      "name": "9_Other_InsName"
    }
  ],
  "info": {
    "year": 2024,
    "version": "1.0",
    "contributor": "Label Studio"
  }
}