{literal} {/literal}
{xl t='Name'} ({xl t='Required'})
{xl t='Attn'}
{xl t='Address'}
{xl t='Address'}
{xl t='City, State Zip'} ,
{xl t='Phone'}
{xl t='CMS ID'} {php} if ($GLOBALS['support_encounter_claims']) { {/php}   {xl t='For Encounter Claims'}: {php} } {/php}
{xl t='Payer Type'} {html_options name="freeb_type" options=$insurancecompany->freeb_type_array selected=$insurancecompany->get_freeb_type()}
{xl t='Default X12 Partner'} {html_options name="x12_default_partner_id" options=$x12_partners selected=$insurancecompany->get_x12_default_partner_id()}
 
{xl t='Save'} {xl t='Cancel'}