ACC Description

<AccDescription>

Description

ACC Number

<acc no.>

Claim Number

Approval Number

<approval no>

From Purchase Num.

Branch Address 1 - 5

<branch address1>
<branch address2>
<branch address3>
<branch address4>
<branch address5>

Branch Contact

<branch contact>

Branch Description

<branch description>

Case Manager

<casemanager>

Case Manager Email

<casemanageremail>

Case Manager Fax

<casemanagerfax>

Case Manager Phone

<casemanagerphone>

Claim Purchase Number

<claim purchase no>

Date of Injury

<date of injury>

Injury Body Side

<InjuryBodySide>

Injury Body Site

<InjuryBodySite>

Injury Cause

<InjuryCause>

Injury Place

<InjuryPlace>

Read Code Descriptions

<ReadCodeDescription>

Read Codes

<ReadCode>