Providers should submit the following patient information as part of the HRSA COVID-19 Uninsured Program:
- First and last name
- Date of birth
- Gender
- *SSN and state of residence; if not available, enter state identification / driver's license
- Date of service for professional, institutional outpatient services.
- Date of admission and date of discharge for institutional inpatient services.
- **Address
- Middle initial (optional)
- Patient account number (optional)
* A SSN and state of residence, or state identification / driver’s license is needed only for the purpose of verifying insurance status. If a SSN and state of residence, or state identification / driver’s license is not submitted, you will need to attest that you attempted to capture this information before submitting a claim and the patient did not have this information at the time of service, or that you did not have direct contact with the patient and thus did not have an opportunity to attempt to capture this information.
**If the individual is unable or unwilling to provide their address, please add the address of the facility where the care was provided or other location that may be appropriate (e.g., shelter).