| # | Name | Location | Type | Details | Index | Description |
|---|---|---|---|---|---|---|
| .01 | date certified(+) | 0;1 | DATE-TIME | B | This field contains the date of annual income certification used in the Beneficial Travel Claim process. | |
| 2 | name(+) | 0;2 | POINTER | 2 | C | This field points to the patient file and contains the IFN for the patient related to this Beneficiary Travel certification date. |
| 3 | eligible(+) | 0;3 | BOOLEAN | 0:NO 1:YES | This field is a set of codes (yes or no) indicating whether this person is eligible for Beneficiary Travel. | |
| 4 | amount certified | 0;4 | NUMERIC | This field is to be used to record the annual income reported by the patient. | ||
| 5 | edited by | 0;5 | POINTER | 200 | This field is a pointer to the new person file and contains the IFN of the person who last edited this Beneficiary Travel Certification date/time. | |
| 6 | last edited | 0;6 | DATE-TIME | This field contains the date this Beneficiary Travel Certification entry was last edited on. | ||
| 11 | address line [1] | A;1 | FREE TEXT | This field contains the first line of the address associated with this Beneficiary Travel Certification date/time. | ||
| 12 | address line [2] | A;2 | FREE TEXT | This field contains the second line of the address associated with this Beneficiary Travel Certification date/time. | ||
| 13 | address line [3] | A;3 | FREE TEXT | This field contains the third line of the address associated with this Beneficiary Travel Certifiction date/time. | ||
| 14 | city | A;4 | FREE TEXT | This field contains the free text 2-30 character name of the City associated with this Beneficiary Travel Certification date/time. | ||
| 15 | state | A;5 | POINTER | 5 | This field points to the State File and contains the IFN of the State associated with this Beneficiary Travel Certification date/time. | |
| 16 | zip | A;6 | FREE TEXT | This field contains the 5-digit zip code associated with this Beneficiary Travel Certification date/time. | ||
| 17 | county code | A;7 | FREE TEXT | This field contains three numeric characters in length for the County Code associated with this Beneficiary Travel Certification date/time. | ||
| 18 | means test status | A;8 | FREE TEXT | This field contains the Means Test Status associated with this Beneficiary Travel Certification date/time. | ||
| 19 | primary eligibility | A;9 | FREE TEXT | This field contains the primary eligibility associated with this Beneficiary Travel Certification date/time. |