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Directions for entering any of the values on the Legal
Entity Detail panel follow:
Protected Field
The panel is displayed with the
Last Name, First Name, MI, and SSN fields (displays for individual practitioners only) already stored by the system and
protected from modification.
or
Organization Name and FEIN
fields (displays for organizations only) fields already stored by
the system and protected from modification.
Drop Down List Box
Select a value from the drop down list box for the Gender
field (displays for individual practitioners only).
Type Values
Type values in the
DOB (if applicable),
Contact,
Address Line 1,
Address Line 2, and
City fields.
Drop Down List Box
Select a value from the drop down list box for the State field.
Type Values
Type values in the
Zip,
Email,
Phone, and
Fax fields.
Type Values
Type values in the
School field (displays for individual practitioners only).
Drop Down List Box
Select a value from the drop down list box for the Degree field (displays for individual practitioners only).
Type Values
Type values in the Year
Of Graduation field (displays for individual practitioners only).
Drop Down List Box
Select a value from the drop down list box for the Ownership Class and Ownership Type fields.
*** Other Legal Entity Detail ******
Radio Buttons
Select an available option, by clicking on a radio button for
the Do you currently participate with other
commercial insurers field.
Drop Down List Box
Select a value from the drop down list box for the If yes select a commercial insurer field.
Radio Buttons
Select an available option, by clicking on a radio button
for the Have you / your organization been
criminally convicted? Have
any agents or employees been criminally convicted? and Are you enrolling solely as a referring, ordering or prescribing practitioner as required by the Affordable Care Act?.
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