| Name | Description | Type | Additional information |
|---|---|---|---|
| Address1 | string |
None. |
|
| Address2 | string |
None. |
|
| City | string |
None. |
|
| State | string |
None. |
|
| Zip | string |
None. |
|
| PayerName | string |
None. |
|
| PayerId | integer |
None. |
|
| InsuranceCode | string |
None. |
|
| PAYERGUID | string |
None. |