Step 1 of 3, ERE: Review/Submit Prepared Request, Social Security

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ERE: Review/Submit Prepared Request

Destination Information
Review & Add Information
Confirmation

Patient Information

Patient Name:

First

Middle

Last

Patient Date Of Birth:

Destination and Request Information

State:

Destination:

Social Security Number (SSN):

RQID (Request ID):

RF (Routing Field):

P
D or Blank
No RF or No Barcode

DR:

F
S
No DR or No Barcode

CS:(enter only if applicable)

User Resources