First Health Services Corporation

Interface Standards • Revised • Form Option Manipulation

Optional system informational message(s) here.

Enter Information | Enter value into text box (or choose from first dropdown). Add to second dropdown.

Enter New Value:
Current Value(s):

Select Information | Use the arrow buttons to add and remove individual, or groups of, items.

Available		Selected

Sort Information | Use the arrow buttons to move selected items in the list.

	Fields

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Assigned Group
Assigned Individual Full Name
Assigned Individual Login
Brand Name Wc
Cardholder Address City
Cardholder Address Line 1
Cardholder Address Line 2
Cardholder Address State
Cardholder Address Zip Code
Cardholder Coverage Effective Date
Cardholder Coverage Termination Date
Cardholder Date Of Birth
Cardholder First Name
Cardholder Gender
Cardholder Group Id
Cardholder Id Number
Cardholder Last Name
Cardholder Plan Id
Cardholder Social Security Number
Claim Authorization Number
Claim Date Of Service
Claim Dispenser Type
Claim Drug Days Supply
Claim Drug Quantity
Claim Prescription Number
Contact Status
Drug Brand Name
Drug Dosage Form
Drug Gsn
Drug Hicl Number
Drug Ndc Number
Drug Standard Therapeutic Class Description
Drug Strength
GCN
HIC3
Issue Category
Issue Create Date
Issue Description
Issue Id Number
Issue Last Modified Date
Issue Priority
Issue Requestor Name
Issue Requestor Phone Extension
Issue Requestor Phone Number
Issue Requestor Type
Issue Response Code
Issue Source
Issue Status
Issue Status Assigned Time
Issue Status Assigned User
Issue Status Closed Time
Issue Status Closed User
Issue Status In Progress Time
Issue Status In Progress User
Issue Status New Time
Issue Status New User
Issue Status Pending Time
Issue Status Pending User
Issue Status Resolved Time
Issue Status Resolved User
Issue Submitter
Issue Type
Patient ID
Patients Favor
Pharmacy Address City
Pharmacy Address Line 1
Pharmacy Address Line 2
Pharmacy Address State
Pharmacy Address Zip Code
Pharmacy Contact Person
Pharmacy Fax Number
Pharmacy Federal Tax Id
Pharmacy Id Number
Pharmacy Name
Pharmacy Phone Number
Physician Address City
Physician Address Line 1
Physician Address Line 2
Physician Address State
Physician Address Zip Code
Physician Cell Phone Number
Physician Fax Number
Physician First Name
Physician Id Number
Physician Last Name
Physician Office Contact Person
Physician Phone Number
Physician Specialty
Relationship To Cardholder
State Id
State Name
Unique Session Id

Assigned Group
Assigned Individual Full Name
Assigned Individual Login
Brand Name Wc
Cardholder Address City
Cardholder Address Line 1
Cardholder Address Line 2
Cardholder Address State
Cardholder Address Zip Code
Cardholder Coverage Effective Date
Cardholder Coverage Termination Date
Cardholder Date Of Birth
Cardholder First Name
Cardholder Gender
Cardholder Group Id
Cardholder Id Number
Cardholder Last Name
Cardholder Plan Id
Cardholder Social Security Number