Jason Jordan
872 lines
36 KiB
XML
872 lines
36 KiB
XML
<?xml version="1.0" encoding="UTF-8"?>
|
||
<jasperReport xmlns="http://jasperreports.sourceforge.net/jasperreports" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" xsi:schemaLocation="http://jasperreports.sourceforge.net/jasperreports http://jasperreports.sourceforge.net/xsd/jasperreport.xsd" name="IDCard" pageWidth="612" pageHeight="792" columnWidth="572" leftMargin="20" rightMargin="20" topMargin="20" bottomMargin="20" uuid="477346fd-960f-44d2-84f5-bd25202741fc">
|
||
<property name="ireport.zoom" value="5.0"/>
|
||
<property name="ireport.x" value="1150"/>
|
||
<property name="ireport.y" value="0"/>
|
||
<parameter name="FamilyId" class="java.lang.String">
|
||
<defaultValueExpression><![CDATA["198621286"]]></defaultValueExpression>
|
||
</parameter>
|
||
<parameter name="BackImage" class="java.lang.String">
|
||
<defaultValueExpression><![CDATA["C:\\images\\All_3_Logo.png"]]></defaultValueExpression>
|
||
</parameter>
|
||
<queryString>
|
||
<![CDATA[Select * From HLIDCardEggData Where FamilyId = $P{FamilyId}]]>
|
||
</queryString>
|
||
<field name="ID" class="java.lang.Integer"/>
|
||
<field name="Facility" class="java.lang.String"/>
|
||
<field name="Division" class="java.lang.String"/>
|
||
<field name="FullName" class="java.lang.String"/>
|
||
<field name="SSN" class="java.lang.String"/>
|
||
<field name="MedicalCoverage" class="java.lang.String"/>
|
||
<field name="MedicalEffDate" class="java.lang.String"/>
|
||
<field name="MedicalGroupNum" class="java.lang.String"/>
|
||
<field name="DentalCoverage" class="java.lang.String"/>
|
||
<field name="DentalEffDate" class="java.lang.String"/>
|
||
<field name="DentalGroupNum" class="java.lang.String"/>
|
||
<field name="CardType" class="java.lang.String"/>
|
||
<field name="ProviderCode" class="java.lang.String"/>
|
||
<field name="ProviderLine1" class="java.lang.String"/>
|
||
<field name="ProviderLine2" class="java.lang.String"/>
|
||
<field name="ProviderLine3" class="java.lang.String"/>
|
||
<field name="ProviderLine4" class="java.lang.String"/>
|
||
<field name="ProviderLine5" class="java.lang.String"/>
|
||
<field name="ProviderLine6" class="java.lang.String"/>
|
||
<field name="ProviderLine7" class="java.lang.String"/>
|
||
<field name="ProviderLine8" class="java.lang.String"/>
|
||
<field name="ProviderLine9" class="java.lang.String"/>
|
||
<field name="ProviderLine10" class="java.lang.String"/>
|
||
<field name="ProviderLine11" class="java.lang.String"/>
|
||
<field name="MailTo" class="java.lang.String"/>
|
||
<field name="MailTo2" class="java.lang.String"/>
|
||
<field name="ClaimTo1" class="java.lang.String"/>
|
||
<field name="ClaimTo2" class="java.lang.String"/>
|
||
<field name="ClaimTo3" class="java.lang.String"/>
|
||
<field name="ClaimTo4" class="java.lang.String"/>
|
||
<field name="ClaimTo5" class="java.lang.String"/>
|
||
<field name="ClaimTo6" class="java.lang.String"/>
|
||
<field name="ClaimTo7" class="java.lang.String"/>
|
||
<field name="ClaimTo8" class="java.lang.String"/>
|
||
<field name="ClaimTo9" class="java.lang.String"/>
|
||
<field name="ClaimTo10" class="java.lang.String"/>
|
||
<field name="ClaimTo11" class="java.lang.String"/>
|
||
<field name="ContactLine1" class="java.lang.String"/>
|
||
<field name="ContactLine2" class="java.lang.String"/>
|
||
<field name="ContactLine3" class="java.lang.String"/>
|
||
<field name="GroupNumber" class="java.lang.String"/>
|
||
<field name="FamilyId" class="java.lang.String"/>
|
||
<field name="GroupNo" class="java.lang.String"/>
|
||
<field name="RXGroupID" class="java.lang.String"/>
|
||
<field name="HelpDesk" class="java.lang.String"/>
|
||
<field name="CustomerService" class="java.lang.String"/>
|
||
<field name="WebUrl" class="java.lang.String"/>
|
||
<field name="Expr1" class="java.lang.String"/>
|
||
<field name="Line3" class="java.lang.String"/>
|
||
<field name="Dependent1" class="java.lang.String"/>
|
||
<field name="Dependent2" class="java.lang.String"/>
|
||
<field name="Dependent3" class="java.lang.String"/>
|
||
<field name="Dependent4" class="java.lang.String"/>
|
||
<field name="Dependent5" class="java.lang.String"/>
|
||
<field name="Dependent6" class="java.lang.String"/>
|
||
<field name="BenDesc1" class="java.lang.String"/>
|
||
<field name="Ben1" class="java.lang.String"/>
|
||
<field name="BenDesc2" class="java.lang.String"/>
|
||
<field name="Ben2" class="java.lang.String"/>
|
||
<field name="BenDesc3" class="java.lang.String"/>
|
||
<field name="Ben3" class="java.lang.String"/>
|
||
<field name="BenDesc4" class="java.lang.String"/>
|
||
<field name="Ben4" class="java.lang.String"/>
|
||
<field name="BenDesc5" class="java.lang.String"/>
|
||
<field name="Ben5" class="java.lang.String"/>
|
||
<field name="BenDesc6" class="java.lang.String"/>
|
||
<field name="Ben6" class="java.lang.String"/>
|
||
<field name="BenDesc7" class="java.lang.String"/>
|
||
<field name="Ben7" class="java.lang.String"/>
|
||
<field name="BenDesc8" class="java.lang.String"/>
|
||
<field name="Ben8" class="java.lang.String"/>
|
||
<field name="BenDesc9" class="java.lang.String"/>
|
||
<field name="Ben9" class="java.lang.String"/>
|
||
<field name="BenDesc10" class="java.lang.String"/>
|
||
<field name="Ben10" class="java.lang.String"/>
|
||
<field name="BenDesc11" class="java.lang.String"/>
|
||
<field name="Ben11" class="java.lang.String"/>
|
||
<field name="BenDesc12" class="java.lang.String"/>
|
||
<field name="Ben12" class="java.lang.String"/>
|
||
<field name="BenDesc13" class="java.lang.String"/>
|
||
<field name="Ben13" class="java.lang.String"/>
|
||
<field name="BenDesc14" class="java.lang.String"/>
|
||
<field name="Ben14" class="java.lang.String"/>
|
||
<field name="PLPlanKey" class="java.lang.Integer"/>
|
||
<field name="PrimaryMBMemberKey" class="java.lang.Integer"/>
|
||
<field name="PPOLookup1" class="java.lang.String"/>
|
||
<field name="PPOLookup2" class="java.lang.String"/>
|
||
<field name="Precert1" class="java.lang.String"/>
|
||
<field name="Precert2" class="java.lang.String"/>
|
||
<field name="Precert3" class="java.lang.String"/>
|
||
<field name="Precert4" class="java.lang.String"/>
|
||
<field name="Precert5" class="java.lang.String"/>
|
||
<field name="Precert6" class="java.lang.String"/>
|
||
<field name="Dependent7" class="java.lang.String"/>
|
||
<field name="Dependent8" class="java.lang.String"/>
|
||
<background>
|
||
<band splitType="Stretch"/>
|
||
</background>
|
||
<title>
|
||
<band splitType="Stretch"/>
|
||
</title>
|
||
<pageHeader>
|
||
<band splitType="Stretch"/>
|
||
</pageHeader>
|
||
<columnHeader>
|
||
<band splitType="Stretch"/>
|
||
</columnHeader>
|
||
<detail>
|
||
<band height="166" splitType="Immediate">
|
||
<rectangle>
|
||
<reportElement uuid="08937bdf-e64e-4836-b222-490c0843272b" mode="Transparent" x="35" y="1" width="250" height="164" forecolor="#00CCFF"/>
|
||
<graphicElement>
|
||
<pen lineWidth="0.5" lineStyle="Dashed"/>
|
||
</graphicElement>
|
||
</rectangle>
|
||
<rectangle>
|
||
<reportElement uuid="7335a19a-8a74-445f-aaa4-e015e3c186f8" mode="Transparent" x="296" y="1" width="250" height="164" forecolor="#00CCFF"/>
|
||
<graphicElement>
|
||
<pen lineWidth="0.5" lineStyle="Dashed"/>
|
||
</graphicElement>
|
||
</rectangle>
|
||
<rectangle>
|
||
<reportElement uuid="4a5b91ca-ebdb-45be-8c16-f6ab6529dae7" x="41" y="15" width="102" height="146"/>
|
||
</rectangle>
|
||
<rectangle>
|
||
<reportElement uuid="e762ee84-c013-417b-a78f-54f6f1f6a1a3" x="439" y="15" width="100" height="84"/>
|
||
</rectangle>
|
||
<rectangle>
|
||
<reportElement uuid="66e1721c-c7fd-40cf-8f45-10b5f6b4c22d" x="440" y="110" width="100" height="44"/>
|
||
</rectangle>
|
||
<rectangle>
|
||
<reportElement uuid="ad8b04e0-5993-4f1c-b6b1-f2c11320be29" x="146" y="15" width="133" height="71"/>
|
||
</rectangle>
|
||
<rectangle>
|
||
<reportElement uuid="777f7302-b52c-48fd-9cf7-6bce02846f86" x="302" y="15" width="133" height="84"/>
|
||
</rectangle>
|
||
<rectangle>
|
||
<reportElement uuid="c654c4f4-6d8f-4678-9a39-99f7394d2690" x="302" y="6" width="53" height="8" backcolor="#000000"/>
|
||
</rectangle>
|
||
<rectangle>
|
||
<reportElement uuid="5c229560-d2d4-4752-95a0-b562e786d29e" x="146" y="6" width="58" height="8" backcolor="#000000"/>
|
||
</rectangle>
|
||
<rectangle>
|
||
<reportElement uuid="014fd155-bf62-4aa6-8a1a-894c0b5855ac" x="439" y="6" width="60" height="8" backcolor="#000000"/>
|
||
</rectangle>
|
||
<rectangle>
|
||
<reportElement uuid="2a360f63-7815-4b72-9ff1-9339cc530b94" x="440" y="102" width="60" height="8" backcolor="#000000"/>
|
||
</rectangle>
|
||
<staticText>
|
||
<reportElement uuid="8417fc69-fdb9-483e-8c7f-9d5a0b91cbc5" x="441" y="6" width="39" height="10" forecolor="#FFFFFF"/>
|
||
<textElement>
|
||
<font size="6" isUnderline="false"/>
|
||
</textElement>
|
||
<text><![CDATA[Eligibility]]></text>
|
||
</staticText>
|
||
<staticText>
|
||
<reportElement uuid="393d9b02-933b-46d8-850b-4d69d148aa86" x="441" y="102" width="58" height="11" forecolor="#FFFFFF"/>
|
||
<textElement>
|
||
<font size="6" isUnderline="false" isPdfEmbedded="false"/>
|
||
</textElement>
|
||
<text><![CDATA[Utilization / Pre-Cert]]></text>
|
||
</staticText>
|
||
<staticText>
|
||
<reportElement uuid="5e18e17a-d437-434d-ad97-fe131a7f2850" x="147" y="6" width="56" height="11" forecolor="#FFFFFF"/>
|
||
<textElement>
|
||
<font size="6" isUnderline="false" isPdfEmbedded="false"/>
|
||
</textElement>
|
||
<text><![CDATA[Claims Submission]]></text>
|
||
</staticText>
|
||
<staticText>
|
||
<reportElement uuid="99f47ca3-1456-4fc7-bb08-a98f460120ce" x="43" y="17" width="98" height="30"/>
|
||
<textElement textAlignment="Center" verticalAlignment="Middle">
|
||
<font size="5" isBold="true" isItalic="false"/>
|
||
</textElement>
|
||
<text><![CDATA[Administered by:
|
||
Britton Benefit Services, LLC
|
||
1.800.676.1182]]></text>
|
||
</staticText>
|
||
<staticText>
|
||
<reportElement uuid="75aa6426-2374-4c07-9556-63dab683cb11" x="439" y="34" width="100" height="16"/>
|
||
<textElement textAlignment="Center" verticalAlignment="Middle">
|
||
<font size="6" isBold="false" isItalic="false"/>
|
||
</textElement>
|
||
<text><![CDATA[To confirm eligibility, verify benefits,
|
||
or check claim:
|
||
]]></text>
|
||
</staticText>
|
||
<staticText>
|
||
<reportElement uuid="8307c61b-9927-4bcc-a825-fec29b5ba605" x="439" y="49" width="100" height="8"/>
|
||
<textElement textAlignment="Center" verticalAlignment="Middle">
|
||
<font size="6" isBold="false" isItalic="false"/>
|
||
</textElement>
|
||
<text><![CDATA[Britton Benefit Services, LLC]]></text>
|
||
</staticText>
|
||
<staticText>
|
||
<reportElement uuid="46c394a4-7df2-4f23-b17e-d8e186e99f5e" x="439" y="61" width="56" height="16"/>
|
||
<textElement textAlignment="Center" verticalAlignment="Middle">
|
||
<font size="6" isBold="false" isItalic="false"/>
|
||
</textElement>
|
||
<text><![CDATA[Call (8am – 5pm):
|
||
1.800.676.1182]]></text>
|
||
</staticText>
|
||
<textField>
|
||
<reportElement uuid="10b2b729-cb2f-4507-99d4-d3286e5ca8ed" x="152" y="16" width="52" height="7"/>
|
||
<textElement verticalAlignment="Middle">
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{ClaimTo1}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="0f23b912-da97-4297-b142-8c47d3332037" x="152" y="21" width="52" height="7"/>
|
||
<textElement verticalAlignment="Middle">
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{ClaimTo2}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="6664081c-30df-4e12-a563-e286fb71935a" x="152" y="26" width="52" height="7"/>
|
||
<textElement verticalAlignment="Middle">
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{ClaimTo3}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="e957833e-54e9-4145-b41b-1a72d0ddadf3" x="152" y="31" width="52" height="7"/>
|
||
<textElement verticalAlignment="Middle">
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{ClaimTo4}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="a49dbbb0-791e-4930-b99a-dfa39ee3e3d9" x="152" y="40" width="52" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{ClaimTo5}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="0b0c6791-76a7-4a76-9695-59fff6544f8f" x="152" y="45" width="52" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{ClaimTo6}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="f1ce64f0-b5fd-499e-a419-e0ef4b1e32e0" x="152" y="50" width="52" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{ClaimTo7}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="2abffded-f4c1-4bfd-bf83-95550d8e1aa3" x="152" y="55" width="52" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{ClaimTo8}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="ed2733a7-5906-4544-a4a6-1e4465c94f70" x="152" y="64" width="52" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{ClaimTo9}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="cc95f964-4572-46b1-b092-964c9f19e7f6" x="152" y="70" width="52" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{ClaimTo10}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="6becfb6d-cb5b-4262-991d-e8d5bc9153c1" x="152" y="76" width="52" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{ClaimTo11}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="94749044-5ec6-4eb4-8f6d-e52ce5e215da" x="206" y="16" width="70" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{ProviderLine1}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="25cbc687-a185-4894-97f4-11d57c8ad84c" x="206" y="21" width="70" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{ProviderLine2}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="527837e8-6ecb-4eba-8b3c-c1fee8e58b52" x="206" y="26" width="70" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{ProviderLine3}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="96e1ff12-6c27-4bd9-b706-050a283ea1a8" x="206" y="31" width="70" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{ProviderLine4}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="c209866f-c8db-455d-8118-ae0aa51204a8" x="206" y="40" width="70" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{ProviderLine5}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="22bcf3ce-6edc-4390-9c63-f169623fdf58" x="206" y="45" width="70" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{ProviderLine6}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="b8bd2df8-9ad2-4cde-9c67-b0e32425c00b" x="206" y="50" width="70" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{ProviderLine7}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="e5d86062-d78f-42b5-b578-cd14dcc071ca" x="206" y="55" width="70" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{ProviderLine8}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="8b542cf4-f0e7-4019-90cf-4b3a826184bf" x="206" y="64" width="70" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{ProviderLine9}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="b154a117-b385-4eac-b53a-51f349d2e9a6" x="206" y="69" width="70" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{ProviderLine10}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="d30067fe-8185-4854-a4da-615d8bb59f4a" x="206" y="76" width="70" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{ProviderLine11}]]></textFieldExpression>
|
||
</textField>
|
||
<staticText>
|
||
<reportElement uuid="8bbea900-0c43-40d8-ad68-2f478aabd3c1" x="305" y="6" width="50" height="11" forecolor="#FFFFFF"/>
|
||
<textElement>
|
||
<font size="6" isUnderline="false" isPdfEmbedded="false"/>
|
||
</textElement>
|
||
<text><![CDATA[Health Benefit Plan]]></text>
|
||
</staticText>
|
||
<rectangle>
|
||
<reportElement uuid="4ecd4a82-edd1-4166-abf9-85d66ebb8b37" x="41" y="6" width="44" height="8" backcolor="#000000"/>
|
||
</rectangle>
|
||
<staticText>
|
||
<reportElement uuid="4ddf1be3-c752-46e0-8197-f4d64b5484b0" x="44" y="6" width="41" height="11" forecolor="#FFFFFF"/>
|
||
<textElement>
|
||
<font size="6" isUnderline="false" isPdfEmbedded="false"/>
|
||
</textElement>
|
||
<text><![CDATA[Medical Plan]]></text>
|
||
</staticText>
|
||
<rectangle>
|
||
<reportElement uuid="1b74e177-da54-47c1-a801-ac0331d2cd11" x="146" y="97" width="133" height="49"/>
|
||
</rectangle>
|
||
<rectangle>
|
||
<reportElement uuid="6a6d5769-ee7e-439f-8d65-7de67cdcb16b" x="146" y="89" width="53" height="8" backcolor="#000000"/>
|
||
</rectangle>
|
||
<staticText>
|
||
<reportElement uuid="fa26d6b7-51d2-4f9e-9d05-9a4513c66eed" x="149" y="89" width="50" height="11" forecolor="#FFFFFF"/>
|
||
<textElement>
|
||
<font size="6" isUnderline="false" isPdfEmbedded="false"/>
|
||
</textElement>
|
||
<text><![CDATA[Pharmacy Plan]]></text>
|
||
</staticText>
|
||
<staticText>
|
||
<reportElement uuid="5c39d2a5-fb6b-427a-ade9-f09c04c1144c" x="304" y="16" width="40" height="8"/>
|
||
<textElement>
|
||
<font size="6" isBold="true"/>
|
||
</textElement>
|
||
<text><![CDATA[Group #/ID:]]></text>
|
||
</staticText>
|
||
<staticText>
|
||
<reportElement uuid="26d1f156-d150-4837-9bba-1390a8199fb4" x="304" y="23" width="19" height="8"/>
|
||
<textElement>
|
||
<font size="6" isBold="true"/>
|
||
</textElement>
|
||
<text><![CDATA[Name:]]></text>
|
||
</staticText>
|
||
<staticText>
|
||
<reportElement uuid="8c0fbf41-d7b6-482b-996d-0b48ee2b0ff7" x="304" y="30" width="32" height="8"/>
|
||
<textElement>
|
||
<font size="6" isBold="true"/>
|
||
</textElement>
|
||
<text><![CDATA[Member #:]]></text>
|
||
</staticText>
|
||
<staticText>
|
||
<reportElement uuid="da2ecd13-2381-494c-9d69-745b2496587e" x="304" y="37" width="50" height="8"/>
|
||
<textElement>
|
||
<font size="6" isBold="true"/>
|
||
</textElement>
|
||
<text><![CDATA[Effective Date:]]></text>
|
||
</staticText>
|
||
<textField>
|
||
<reportElement uuid="1361e8b7-6ea2-4f2b-a6fd-781b1fa521e8" x="346" y="16" width="88" height="8"/>
|
||
<textElement>
|
||
<font size="6"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{GroupNo}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="c2877613-bc27-4175-b080-5ab67f1d781c" x="323" y="23" width="111" height="8"/>
|
||
<textElement>
|
||
<font size="6"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{FullName}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="acea13af-f269-47da-b9cc-ba0ea22df29f" x="336" y="30" width="98" height="8"/>
|
||
<textElement>
|
||
<font size="6"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{PrimaryMBMemberKey}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="eaa738bf-1ced-4c86-8a31-9acc09a88abe" x="346" y="37" width="88" height="8"/>
|
||
<textElement>
|
||
<font size="6"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{MedicalEffDate}]]></textFieldExpression>
|
||
</textField>
|
||
<staticText>
|
||
<reportElement uuid="cf1ce1ca-5cef-436c-b2d6-26bd3e1015b4" x="304" y="62" width="76" height="8"/>
|
||
<textElement>
|
||
<font size="6" isBold="true"/>
|
||
</textElement>
|
||
<text><![CDATA[Covered Dependents:]]></text>
|
||
</staticText>
|
||
<textField>
|
||
<reportElement uuid="848389f8-98f1-41da-962e-cc29aeac91d1" x="305" y="69" width="63" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Dependent1}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="adee7873-b80c-4be4-9568-533471bab640" x="305" y="76" width="63" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Dependent2}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="53ed1fe8-89ed-42a2-98bb-9ad75418f543" x="305" y="83" width="63" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Dependent3}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="07c29443-8589-4e0f-a758-b69a34f38b07" x="305" y="90" width="63" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Dependent4}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="f906328d-53c5-4bb7-b4d4-4eba2261adfb" x="371" y="69" width="63" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Dependent5}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="a15671c2-f677-4def-9d42-1e0553d43010" x="371" y="76" width="63" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Dependent6}]]></textFieldExpression>
|
||
</textField>
|
||
<image scaleImage="RetainShape" hAlign="Center">
|
||
<reportElement uuid="36c204c6-c2f7-4613-863f-332cf50ff6cc" x="202" y="100" width="76" height="21"/>
|
||
<imageExpression><![CDATA["C:\\images\\HealthBusLogo.jpg"]]></imageExpression>
|
||
</image>
|
||
<staticText>
|
||
<reportElement uuid="40b57f3b-eeeb-4e38-857b-6bf290bb5ba5" x="148" y="101" width="25" height="8"/>
|
||
<textElement>
|
||
<font size="5" isBold="true"/>
|
||
</textElement>
|
||
<text><![CDATA[RX Bin:]]></text>
|
||
</staticText>
|
||
<staticText>
|
||
<reportElement uuid="cc922142-d87a-4f04-b28b-413ad513e5e0" x="148" y="110" width="31" height="8"/>
|
||
<textElement>
|
||
<font size="5" isBold="true"/>
|
||
</textElement>
|
||
<text><![CDATA[RX PCN:]]></text>
|
||
</staticText>
|
||
<staticText>
|
||
<reportElement uuid="4534f9a0-901a-402c-86ba-0b3109370e53" x="148" y="120" width="31" height="8"/>
|
||
<textElement>
|
||
<font size="5" isBold="true"/>
|
||
</textElement>
|
||
<text><![CDATA[RX GRP:]]></text>
|
||
</staticText>
|
||
<staticText>
|
||
<reportElement uuid="abd7fb37-b19a-4691-869c-28a8c0b326ce" x="175" y="101" width="27" height="8"/>
|
||
<textElement>
|
||
<font size="5" isBold="true"/>
|
||
</textElement>
|
||
<text><![CDATA[024144]]></text>
|
||
</staticText>
|
||
<staticText>
|
||
<reportElement uuid="84e6427e-950d-4c1a-877e-a342ec8009db" x="175" y="110" width="27" height="8"/>
|
||
<textElement>
|
||
<font size="5" isBold="true"/>
|
||
</textElement>
|
||
<text><![CDATA[healthbus]]></text>
|
||
</staticText>
|
||
<textField>
|
||
<reportElement uuid="709713dc-5f48-40dc-957c-9f015b376b41" x="175" y="120" width="49" height="8"/>
|
||
<textElement>
|
||
<font size="5" isBold="true"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{RXGroupID}]]></textFieldExpression>
|
||
</textField>
|
||
<staticText>
|
||
<reportElement uuid="00b86af7-1cba-4c7a-a78b-cb0ffa476f88" x="148" y="134" width="58" height="8"/>
|
||
<textElement>
|
||
<font size="5" isBold="true"/>
|
||
</textElement>
|
||
<text><![CDATA[Customer Service:]]></text>
|
||
</staticText>
|
||
<textField>
|
||
<reportElement uuid="0bce3d0c-c01b-4dfd-9638-19b94d75e73e" x="205" y="120" width="73" height="8"/>
|
||
<textElement textAlignment="Center">
|
||
<font size="5" isBold="true"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{WebUrl}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="1193b1ef-31e9-4c43-bb51-236b67c21c81" x="205" y="134" width="73" height="8"/>
|
||
<textElement>
|
||
<font size="5" isBold="true"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{CustomerService}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="ded7012f-9a8d-4e97-876b-e34bc59241ef" x="43" y="61" width="52" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{BenDesc1}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="2a63ebda-6cf8-4f7a-927b-7cfa892e196d" x="98" y="61" width="43" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Ben1}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="aa510ad0-1a1e-4f24-b692-505794f4f159" x="43" y="68" width="52" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{BenDesc2}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="f501005d-ba2b-4747-92f4-1b3288d52f3a" x="98" y="68" width="43" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Ben2}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="fae8e590-1ffe-4e48-aef6-26a7e01c88af" x="43" y="75" width="52" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{BenDesc3}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="693746af-9ba2-4992-a270-397eaac04653" x="43" y="82" width="52" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{BenDesc4}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="27282b06-831e-40e5-93ee-ca77e3190dd5" x="98" y="75" width="43" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Ben3}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="fb423834-c0e0-4e68-8dd9-baa62eaa79a2" x="98" y="82" width="43" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Ben4}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="b0e3223c-1930-42db-82cc-d059e9b699b9" x="43" y="89" width="52" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{BenDesc5}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="bae3a6b6-1ca2-4ca6-9ba1-dd5fb9d1153f" x="98" y="110" width="43" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Ben8}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="8afd99dc-91b9-4416-806a-5f0e7eb83b1c" x="43" y="110" width="52" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{BenDesc8}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="c88d8d15-070c-42ad-999c-2e013f399992" x="43" y="103" width="52" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{BenDesc7}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="8bfb12fe-aef3-4397-a026-1fe43ebce05e" x="43" y="96" width="52" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{BenDesc6}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="43a569a5-7de5-427a-986f-bc4af746be06" x="98" y="96" width="43" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Ben6}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="a26646b1-152c-44f2-9486-1bd1590683c3" x="98" y="103" width="43" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Ben7}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="b572b49b-7b9a-4f68-b7ef-11dfadd2dae4" x="98" y="89" width="43" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Ben5}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="cc80102a-5811-4dc6-8d44-606d736bddc7" x="148" y="140" width="8" height="7"/>
|
||
<textElement>
|
||
<font fontName="Microsoft Sans Serif" size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{ProviderCode}.equals("1")?"S":""]]></textFieldExpression>
|
||
</textField>
|
||
<image hAlign="Center">
|
||
<reportElement uuid="ea716b2c-5586-439d-8450-7302d49a5bd3" x="303" y="103" width="100" height="51"/>
|
||
<imageExpression><![CDATA["C:\\images\\CignaLogo.png"]]></imageExpression>
|
||
</image>
|
||
<image>
|
||
<reportElement uuid="7da52da7-1e66-4ba2-ae1c-8ba65b8797c3" x="191" y="149" width="189" height="8"/>
|
||
<imageExpression><![CDATA["C:\\images\\LOGO - AFHC.jpg"]]></imageExpression>
|
||
</image>
|
||
<staticText>
|
||
<reportElement uuid="4da0cb27-87c4-4f6c-8cde-4078ad224da6" x="414" y="156" width="132" height="8"/>
|
||
<textElement>
|
||
<font size="6" isBold="true"/>
|
||
</textElement>
|
||
<text><![CDATA[Benefits are not insured by Cigna or affiliates]]></text>
|
||
</staticText>
|
||
<textField isBlankWhenNull="true">
|
||
<reportElement uuid="e1932f2f-82d4-491b-a3a3-b8151ac539e2" x="98" y="117" width="43" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Ben9}]]></textFieldExpression>
|
||
</textField>
|
||
<textField isBlankWhenNull="true">
|
||
<reportElement uuid="a064a7fd-da67-407f-838d-4d0a5b267843" x="43" y="117" width="52" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{BenDesc9}]]></textFieldExpression>
|
||
</textField>
|
||
<textField isBlankWhenNull="true">
|
||
<reportElement uuid="ab233e66-e9cd-4224-8a46-bf57655ef118" x="43" y="124" width="52" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{BenDesc10}]]></textFieldExpression>
|
||
</textField>
|
||
<textField isBlankWhenNull="true">
|
||
<reportElement uuid="286a851b-e65e-4fa2-bae1-161ed10a131c" x="98" y="124" width="43" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Ben10}]]></textFieldExpression>
|
||
</textField>
|
||
<textField isBlankWhenNull="true">
|
||
<reportElement uuid="920cb788-6331-4e5c-8f8f-f94c8be5a994" x="43" y="131" width="52" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{BenDesc11}]]></textFieldExpression>
|
||
</textField>
|
||
<textField isBlankWhenNull="true">
|
||
<reportElement uuid="30aeb39b-dc3b-41a1-9d68-642c0f9bcb97" x="98" y="131" width="43" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Ben11}]]></textFieldExpression>
|
||
</textField>
|
||
<textField isBlankWhenNull="true">
|
||
<reportElement uuid="f8c77d6d-09fd-4b82-aae0-e9d6fdc2d30f" x="43" y="138" width="52" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{BenDesc12}]]></textFieldExpression>
|
||
</textField>
|
||
<textField isBlankWhenNull="true">
|
||
<reportElement uuid="d29a0a9b-974d-43c6-bb2a-9a299abffc63" x="98" y="138" width="43" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Ben12}]]></textFieldExpression>
|
||
</textField>
|
||
<textField isBlankWhenNull="true">
|
||
<reportElement uuid="a8518713-b138-4ffe-aa62-0569c1d9a994" x="43" y="145" width="52" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{BenDesc13}]]></textFieldExpression>
|
||
</textField>
|
||
<textField isBlankWhenNull="true">
|
||
<reportElement uuid="26483625-94c7-40e6-bde9-c9be49a05cb5" x="98" y="145" width="43" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Ben13}]]></textFieldExpression>
|
||
</textField>
|
||
<textField isBlankWhenNull="true">
|
||
<reportElement uuid="34bf0565-21e2-4f28-b7e9-8002d413c604" x="43" y="152" width="52" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{BenDesc14}]]></textFieldExpression>
|
||
</textField>
|
||
<textField isBlankWhenNull="true">
|
||
<reportElement uuid="34649417-951f-406a-8ab8-b30d019d5017" x="98" y="152" width="43" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Ben14}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="bb76fe99-8d7a-4089-b690-86be4c3c289d" x="371" y="83" width="63" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Dependent7}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="36c1c7bb-72e0-4cfe-bdf6-f2aeb9fd7a61" x="371" y="90" width="63" height="7"/>
|
||
<textElement>
|
||
<font size="5"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Dependent8}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="55d08a64-2edd-42bf-9d7c-a6bf4dc5c264" x="441" y="115" width="98" height="8"/>
|
||
<textElement textAlignment="Center">
|
||
<font size="6"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Precert1}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="63a44103-596e-4a2d-b37f-ba2d864b5153" x="441" y="125" width="98" height="8"/>
|
||
<textElement textAlignment="Center">
|
||
<font size="6"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Precert2}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="97ff0bc5-dc53-4bec-91fb-8fa7ae6af739" x="441" y="135" width="98" height="8"/>
|
||
<textElement textAlignment="Center">
|
||
<font size="6"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Precert3}]]></textFieldExpression>
|
||
</textField>
|
||
<textField>
|
||
<reportElement uuid="4c7f6e21-68ed-4000-96f0-105149e8d087" x="441" y="145" width="98" height="8"/>
|
||
<textElement textAlignment="Center">
|
||
<font size="6"/>
|
||
</textElement>
|
||
<textFieldExpression><![CDATA[$F{Precert4}]]></textFieldExpression>
|
||
</textField>
|
||
<staticText>
|
||
<reportElement uuid="87828963-9211-4771-8d96-ce8bbd2ed2f0" x="439" y="15" width="100" height="16"/>
|
||
<textElement textAlignment="Center" verticalAlignment="Middle">
|
||
<font size="6" isBold="false" isItalic="false"/>
|
||
</textElement>
|
||
<text><![CDATA[This card does not
|
||
guarantee eligibility or payment.]]></text>
|
||
</staticText>
|
||
<staticText>
|
||
<reportElement uuid="bf34fc0f-2e5a-4e7a-9037-8cd394dcd903" x="439" y="80" width="56" height="16"/>
|
||
<textElement textAlignment="Center" verticalAlignment="Middle">
|
||
<font size="6" isBold="false" isItalic="false"/>
|
||
</textElement>
|
||
<text><![CDATA[(24/7) Online
|
||
www.bbstpa.com]]></text>
|
||
</staticText>
|
||
<image scaleImage="RealSize" hAlign="Center">
|
||
<reportElement uuid="a0ff5d26-39c7-4104-83d4-9f0e7c5c5fb4" x="495" y="60" width="35" height="32"/>
|
||
<imageExpression><![CDATA["C:\\images\\BrittonEligibilityQRCode.png"]]></imageExpression>
|
||
</image>
|
||
<staticText>
|
||
<reportElement uuid="2e9ad64b-9721-4312-8d61-5ce36ab659b8" x="43" y="52" width="42" height="8"/>
|
||
<textElement>
|
||
<font size="5" isBold="true"/>
|
||
</textElement>
|
||
<text><![CDATA[Patient Cost:]]></text>
|
||
</staticText>
|
||
</band>
|
||
</detail>
|
||
<columnFooter>
|
||
<band splitType="Stretch"/>
|
||
</columnFooter>
|
||
<pageFooter>
|
||
<band splitType="Stretch"/>
|
||
</pageFooter>
|
||
<summary>
|
||
<band splitType="Stretch"/>
|
||
</summary>
|
||
</jasperReport>
|