| Name | Value |
|---|---|
| FORM FIELD REFERENCE | LEGACY HCFA-1500 |
| SECURITY LEVEL | NATIONAL,NO EDIT |
| DATA ELEMENT | N-HCFA 1500 BOX 12 |
| PAD CHARACTER | NO PAD REQUIRED |
| FORMAT CODE | N IBZ D F^IBCEF("N-ROI INDICATOR","IBZ") I IBZ S IBXDATA="MODIFIED/RESTRICTED RELEASE "_IBXDATA |