\n
Insurance Information \n {{#unless\n (in-array\n (if (eq this.insurance.insuranceType \"Primary\") this.priHiddenFields this.secHiddenFields)\n \"insuranceProvider\"\n )\n }}\n
\n {{this.prefixLabel}} Provider \n {{this.insurance.insuranceProvider.name}}\n
\n {{/unless}}\n \n {{#unless\n (in-array\n (if (eq this.insurance.insuranceType \"Primary\") this.priHiddenFields this.secHiddenFields) \"idNumber\"\n )\n }}\n
\n {{this.prefixLabel}} ID # \n {{this.insurance.idNumber}}\n
\n {{/unless}}\n {{#unless\n (in-array\n (if (eq this.insurance.insuranceType \"Primary\") this.priHiddenFields this.secHiddenFields)\n \"subscriberNumber\"\n )\n }}\n
\n {{this.prefixLabel}} Subscriber # \n {{this.insurance.subscriberNumber}}\n
\n {{/unless}}\n {{#unless\n (in-array\n (if (eq this.insurance.insuranceType \"Primary\") this.priHiddenFields this.secHiddenFields) \"groupNumber\"\n )\n }}\n
\n {{this.prefixLabel}} Group # \n {{this.insurance.groupNumber}}\n
\n {{/unless}}\n \n {{#unless\n (in-array\n (if (eq this.insurance.insuranceType \"Primary\") this.priHiddenFields this.secHiddenFields)\n \"relationshipToInsured\"\n )\n }}\n
\n Relationship To Insured \n {{this.insurance.relationshipToInsured}}\n
\n {{/unless}}\n {{#unless\n (in-array\n (if (eq this.insurance.insuranceType \"Primary\") this.priHiddenFields this.secHiddenFields)\n \"nameOfPersonInsured\"\n )\n }}\n
\n Name of Person Insured \n {{this.insurance.nameOfPersonInsured}}\n
\n {{/unless}}\n {{#unless\n (in-array\n (if (eq this.insurance.insuranceType \"Primary\") this.priHiddenFields this.secHiddenFields)\n \"dobOfInsured\"\n )\n }}\n
\n Insured Date of Birth \n {{date-time-formatter this.insurance.dobOfInsured this.organization.dateOutputFormat}}\n
\n {{/unless}}\n \n {{#unless\n (in-array\n (if (eq this.insurance.insuranceType \"Primary\") this.priHiddenFields this.secHiddenFields)\n \"insuredEmail\"\n )\n }}\n
\n Insured Email \n {{this.insurance.insuredEmail}}\n
\n {{/unless}}\n \n {{#unless\n (in-array\n (if (eq this.insurance.insuranceType \"Primary\") this.priHiddenFields this.secHiddenFields) \"insuredSex\"\n )\n }}\n
\n Insured Sex \n {{this.insurance.displaySex}}\n
\n {{/unless}}\n \n {{#unless\n (in-array\n (if (eq this.insurance.insuranceType \"Primary\") this.priHiddenFields this.secHiddenFields)\n \"insuredStreetAddress\"\n )\n }}\n
\n Insured Street Address \n {{this.insurance.insuredStreetAddress}}\n
\n {{/unless}}\n {{#unless\n (in-array\n (if (eq this.insurance.insuranceType \"Primary\") this.priHiddenFields this.secHiddenFields)\n \"insuredStreetAddressLine2\"\n )\n }}\n
\n Insured Street Address Line 2 \n {{this.insurance.insuredStreetAddressLine2}}\n
\n {{/unless}}\n {{#unless\n (in-array\n (if (eq this.insurance.insuranceType \"Primary\") this.priHiddenFields this.secHiddenFields) \"insuredCity\"\n )\n }}\n
\n Insured City \n {{this.insurance.insuredCity}}\n
\n {{/unless}}\n {{#unless\n (in-array\n (if (eq this.insurance.insuranceType \"Primary\") this.priHiddenFields this.secHiddenFields)\n \"insuredState\"\n )\n }}\n
\n Insured State \n {{this.insurance.insuredState}}\n
\n {{/unless}}\n {{#unless\n (in-array\n (if (eq this.insurance.insuranceType \"Primary\") this.priHiddenFields this.secHiddenFields)\n \"insuredZipCode\"\n )\n }}\n
\n Insured Zip Code \n {{this.insurance.insuredZipCode}}\n
\n {{/unless}}\n \n
\n {{#if this.insurance.preAuthorization.id}}\n
{{this.insurance.insuranceType}} Pre Authorization \n \n {{#unless\n (in-array\n (if\n (eq this.insurance.insuranceType \"Primary\") this.priPreAuthHiddenFields this.secPreAuthHiddenFields\n )\n \"authorizationNumber\"\n )\n }}\n
\n Authorization Number \n {{this.insurance.preAuthorization.authorizationNumber}}\n
\n {{/unless}}\n {{#unless\n (in-array\n (if\n (eq this.insurance.insuranceType \"Primary\") this.priPreAuthHiddenFields this.secPreAuthHiddenFields\n )\n \"numAllowedTests\"\n )\n }}\n
\n Allowed Tests \n {{this.insurance.preAuthorization.numAllowedTests}}\n
\n {{/unless}}\n {{#unless\n (in-array\n (if\n (eq this.insurance.insuranceType \"Primary\") this.priPreAuthHiddenFields this.secPreAuthHiddenFields\n )\n \"effectiveStartDate\"\n )\n }}\n
\n Effective Start Date \n {{date-time-formatter\n this.insurance.preAuthorization.effectiveStartDate\n this.organization.dateOutputFormat\n }}\n
\n {{/unless}}\n {{#unless\n (in-array\n (if\n (eq this.insurance.insuranceType \"Primary\") this.priPreAuthHiddenFields this.secPreAuthHiddenFields\n )\n \"effectiveEndDate\"\n )\n }}\n
\n Effective End Date \n {{date-time-formatter\n this.insurance.preAuthorization.effectiveEndDate\n this.organization.dateOutputFormat\n }}\n
\n {{/unless}}\n {{#unless\n (in-array\n (if\n (eq this.insurance.insuranceType \"Primary\") this.priPreAuthHiddenFields this.secPreAuthHiddenFields\n )\n \"contactName\"\n )\n }}\n
\n Contact Name \n {{this.insurance.preAuthorization.contactName}}\n
\n {{/unless}}\n {{#unless\n (in-array\n (if\n (eq this.insurance.insuranceType \"Primary\") this.priPreAuthHiddenFields this.secPreAuthHiddenFields\n )\n \"contactPhoneNumber\"\n )\n }}\n
\n Contact Phone Number \n {{this.insurance.preAuthorization.contactPhoneNumber}}\n
\n {{/unless}}\n {{/if}}\n
\n \n