Name, Middle C Text 30 ST Second And Further Given Names Or Initials Thereof 3 Relationship O Alphanumeric 250 CE Relationship 5 Phone Number Home 250 XTN Number Home C Numeric 199 ST Telephone Number – Number Cell C Numeric 199 ST Telephone Number – Address Home O Alphanumeric 199 ST Email Address – 6 Phone Number Business 250 XTN Phone Number Business C Numeric 199 ST Telephone Number – Phone Number Fax C Numeric 199 ST Telephone Number – Email Address Business O Alphanumeric 199 ST Email Address – 2 Legal Representative Name O 250 XPN Name Name, Prefix O Text 20 ST Prefix Name, Last R Text 194 FN Family Name Name, Suffix C Alphanumeric 20 ST Suffix Name, First R Alphanumeric 30 ST Name Name, Middle C Text 30 ST Second And Further Given Names Or Initials Thereof 3 Type of Legal Representative C Alphanumeric 250 CE Relationship (Surrogate Decision Maker, Guardian, Conservator, Durable Power of Attorney HC),, 4 Legal Representative Address 250 XAD Address Building Number R Alphanumeric 12 SAD Dwelling Number Line 1 (Street Name) R Alphanumeric 184 SAD Street Address Line 2 (Apt. No or Unit No) O Alphanumeric 120 ST Street Address City R Text 50 ST City County R Text 20 IS County State/Province R Text 50 ST State or Province Zip Code R Alphanumeric 12 ST Zip or Postal Code Country R Text 3 ID Country 5 Legal Representative Phone 250 XTN Number Home Phone Number Home C Numeric 199 ST Telephone Number – Phone Number Cell C Numeric 199 ST Telephone Number – Email Address Home O Alphanumeric 199 ST Email Address – 6 Representative Phone 250 XTN Number Business Number Business C Numeric 199 ST Telephone Number – Number Fax C Numeric 199 ST Telephone Number – Email Address Business O Alphanumeric 199 ST Email Address – Legal Representative Occupational Information 34 Employment Status O Text 250 CE Job Status
Name, Middle C Text 30 ST Second And Further Given Names Or Initials Thereof 3 Relationship O Alphanumeric 250 CE Relationship 5 Phone Number Home 250 XTN Number – Home C Numeric 199 ST Telephone Number Number – Cell C Numeric 199 ST Telephone Number Address – Home O Alphanumeric 199 ST Email Address 6 Phone Number Business 250 XTN Phone Number – Business C Numeric 199 ST Telephone Number Phone Number – Fax C Numeric 199 ST Telephone Number Email Address – Business O Alphanumeric 199 ST Email Address 2 Legal Representative Name O 250 XPN Name Name, Prefix O Text 20 ST Prefix Name, Last R Text 194 FN Family Name Name, Suffix C Alphanumeric 20 ST Suffix Name, First R Alphanumeric 30 ST Name Name, Middle C Text 30 ST Second And Further Given Names Or Initials Thereof 3 Type of Legal Representative (Surrogate Decision Maker, Guardian, Conservator, Durable Power of Attorney HC),, C Alphanumeric 250 CE Relationship 4 Legal Representative Address 250 XAD Address Building Number R Alphanumeric 12 SAD Dwelling Number Line 1 (Street Name) R Alphanumeric 184 SAD Street Address Line 2 (Apt. No or Unit No) O Alphanumeric 120 ST Street Address City R Text 50 ST City County R Text 20 IS County State/Province R Text 50 ST State or Province Zip Code R Alphanumeric 12 ST Zip or Postal Code Country R Text 3 ID Country 5 Legal Representative Phone Number Home 250 XTN Phone Number – Home C Numeric 199 ST Telephone Number Phone Number – Cell C Numeric 199 ST Telephone Number Email Address – Home O Alphanumeric 199 ST Email Address 6 Representative Phone Number Business 250 XTN Number – Business C Numeric 199 ST Telephone Number Number – Fax C Numeric 199 ST Telephone Number Email Address – Business O Alphanumeric 199 ST Email Address Legal Representative Occupational Information 34 Employment Status O Text 250 CE Job Status
AHIMAChecklistUseCase-PtRegistration-01-04-17.docx