, employer information, and referral procedures. adiustcr name and ohonc number. no payment is necessary at the time of the visit. O Uninsured or Major Medical only Paying for services at the time of the visit. Work with you to settle your account. O Third Party Liability and Accident victims Paying for

epartment Head or Branch Manager Administrative Partner Director of Per ADP CODES CATEGORY 0 1 2 3 4 5 6 7 8 9 Effective Date 401 t Major Medical 402 Blue Cross 403 Type Employee 404 Birth Date 392 V ;Oi l / Annual Salary 762 Clock Number . 330 '',7 /Y/ 7/ 354 Rev. 1O/75 (8/7O