Transfer from Account Type

Please select Suspense ADVN – Advance Holding HOLD – Holding FEE – Fee Contract MEDICAL – Medical Plan Contract

Include Applied Payments

Entered Amount

Reason Code

None – Clear Selection R001 – Binder Payment R002 – Payment Transferred R003 – Entity Transfer

Available Account Balance:

$0.00

Total Entered:

$0.00

Difference:

$0.00

Line Receipt ID Amount Holding Account Group ID Subgroup ID Subscriber ID Billing Period Billing Group AFA ID Reason Code Contract ID 1 -- None – Clear Selection Suspense Advanced Holding Holding None – Clear Selection R001 – Binder Payment R002 – Payment Transferred R003 – Entity Transfer None – Clear Selection HMOGOLD – HMO Gold Plan PPODENT– PPO Dental Plan