What type of unique identifiable identification information is required when submitting patient information?

• First and last name
• Date of birth
• Gender
• Date of service
• Primary insurance information and policy number
• Address*
• Middle initial (optional)
• Patient account number (optional)

*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).