Name
Attn
Address
Address
City, State Zip ,
Phone
CMS ID
Payer Type {html_options name="freeb_type" options=$insurancecompany->freeb_type_array selected=$insurancecompany->get_freeb_type()}
Default X12 Partner {html_options name="x12_default_partner_id" options=$x12_partners selected=$insurancecompany->get_x12_default_partner_id()}