| A | B |
|---|
| LAST NAME | WILL AUTO-POPULATE WITH THE SUBSCRIBER'S LAST NAME |
| GENDER | WILL AUTO-POPULATE BASED ON RELATIONSHIP |
| ADDRESS SELECT SUBSECTION | USE ONLY IF MEMBER'S ADDRESS IS DIFFERENT THAN SUBSCRIBER'S |
| COB SUBSECTION | THIS SUBSECTION MUST BE COMPLETED TO FLAG CLAIMS TO INVESTIGATE |
| CLAIMS PAY HOLD SUBSECTION | IS NOT APPLICABLE FOR THE ENROLLMENT PROCESS |
| TEXT FIELD OF THE NOTES SUBSECTION | FREE FORM TEXT FIELD HOLDING OVER 800 LINES |
| ELIGIBILITY SECTION | USED IN BOTH THE ADD A NEWBORN AND ADD A MEMBER PROCESSES |
| ORDER | PRIMARY, SECONDARY OR UNKNOWN |
