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truForm: Medims - Integration Fields

The TruForm integration requires no additional charge from PBHS, and can be setup at anytime with your PBHS TruForm order. Please contact PBHS Support further if you are ready to start this process.

Once the integration settings are added to your form(s) and truForm account, you will need to set your own integration credentials through your new truForm account's profile settings and provide this information to your software representative directly (PBHS does not have access to this information). Instructions on setting your integration credentials through the portal can be found HERE (COMING SOON).

*Please note, you will need to contact your software provider to obtain more information about the pricing for their TruForm bridge, as there may be additional fees.

Integration

Below are ALL fields that integrate between TruForm and Medims. If your custom form is setup correctly, items listed below will populate within your software.

The form itself will populate into the patients file as a downloadable attachment. 

Note, if you have additional fields on your form that are NOT listed below, you can manually enter them into your patient's account once integration is completed!

If you use our standard form below, the sections listed below are already integrated!

Field Count:  165 total fields integrate into your PMS!

  1. Patient Information

  2. Responsible Party Information
  3. School and Insurance Information
  4. Insurance Information

PATIENT INFORMATION

*IF YOU ARE USING A CUSTOM FORM:

  • Patient Name on the form must be split out into first name last name in order to integrate correctly.
  • Patient Address/ City/ State / Zip must be split out into its own fields in order to integrate correctly.
  • Dentist/Doctor/Referred By Names on the form must be split out into first name last name in order to integrate correctly.
  1. Prefix
  2. First Name
  3. Last name
  4. Middle Initial
  5. Suffix
  6. Gender
  7. Date of Birth
  8. Social Security Number
  9. Work Phone
  10. Home Phone
  11. Cell Phone
  12. Email Address
  1. Address Street Name
  2. Address Apt
  3. City
  4. State or Province 
  5. Zip or Postal Code
  6. Drivers License
  7. Employment Status
  8. Employer Name
  9. Employer Address
  10. City, State Zip
  1. Dentist First Name
  2. Dentist Last Name
  3. Doctor First Name
  4. Doctor Last Name
  5. Referred by First Name
  6. Referred by Last Name
  7. Emergency Full Name
  8. Phone Home
  9. Relation

 

RESPONSIBLE PARTY INFORMATION

*IF YOU ARE USING A CUSTOM FORM: 

  • Responsible Name on the form must be split out into first name last name in order to integrate correctly. 
  • Responsible Party Address/ City/ State / Zip must be split out into its own fields in order to integrate correctly.   
  1. Relationship Description
  2. First Name
  3. Last Name
  4. Social Security Number
  5. Date of Birth
  6. Email
  7. Drivers License
  1. Address Street Name
  2. Address Street Name 2
  3. City
  4. State or Province
  5. Zip or Postal Code
  6. Employer Name
  7. Home Phone
  8. Work Phone
  9. Cell Phone

 

SCHOOL AND INSURANCE INFORMATION

*IF YOU ARE USING A CUSTOM FORM:

  • School Name/ Address/ City/ State / Zip must be split out into its own fields in order to integrate correctly.
  1. School Status
  2. School Name
  3. School Address
  4. City
  5. State or Province 
  6. Zip or Postal Code
  1. School Phone
  2. Marital Status
  3. Employed Status

 

INSURANCE INFORMATION

*IF YOU ARE USING A CUSTOM FORM: 

  • Each insurance type (primary medical, primary dental, secondary medical, secondary dental must be separated into its own area for each question below in order to integrate correctly.
  • All Address/ City/ State must be split out into its own fields in order to integrate correctly.
  • Insured Name on the form must be split out into first name last name in order to integrate correctly.

PRIMARY DENTAL

  1. Employer Name
  2. Employer Address Street Name
  3. Employer City
  4. Employer State or Province 
  5. Employer Zip or Postal Code
  6. Employer Work Phone
  7. Employer Plan Name
  8. Insurance Company Name
  9. Insurance Company ID
  10. Insurance Company Address Street Name
  11. Insurance Company City
  12. Insurance Company State or Province
  13. Insurance Company Zip or Postal Code
  14. Insurance Company Phone
  15. Insurance Company Group Name
  16. Insurance Company Group Number
  17. Insured First Name
  18. Insured Last Name
  19. Insured Relation to Patient
  20. Insured Birthdate
  21. Insured Gender
  22. Insured Social Security Number
  23. Insured Home Phone
  24. Insured Address Street Name
  25. Insured City
  26. Insured State or Province
  27. Insured Zip or Postal 

SECONDARY DENTAL

  1. Employer Name
  2. Employer Address Street Name
  3. Employer City
  4. Employer State or Province 
  5. Employer Zip or Postal Code
  6. Employer Work Phone
  7. Employer Plan Name
  8. Insurance Company Name
  9. Insurance Company ID
  10. Insurance Company Address Street Name
  11. Insurance Company City
  12. Insurance Company State or Province
  13. Insurance Company Zip or Postal Code
  14. Insurance Company Phone
  15. Insurance Company Group Name
  16. Insurance Company Group Number
  17. Insured First Name
  18. Insured Last Name
  19. Insured Relation to Patient
  20. Insured Birthdate
  21. Insured Gender
  22. Insured Social Security Number
  23. Insured Home Phone
  24. Insured Address Street Name
  25. Insured City
  26. Insured State or Province
  27. Insured Zip or Postal 

PRIMARY MEDICAL

  1. Employer Name
  2. Employer Address Street Name
  3. Employer City
  4. Employer State or Province 
  5. Employer Zip or Postal Code
  6. Employer Work Phone
  7. Employer Plan Name
  8. Insurance Company Name
  9. Insurance Company ID
  10. Insurance Company Address Street Name
  11. Insurance Company City
  12. Insurance Company State or Province
  13. Insurance Company Zip or Postal Code
  14. Insurance Company Phone
  15. Insurance Company Group Name
  16. Insurance Company Group Number
  17. Insured First Name
  18. Insured Last Name
  19. Insured Relation to Patient
  20. Insured Birthdate
  21. Insured Gender
  22. Insured Social Security Number
  23. Insured Home Phone
  24. Insured Address Street Name
  25. Insured City
  26. Insured State or Province
  27. Insured Zip or Postal 

SECONDARY MEDICAL

  1. Employer Name
  2. Employer Address Street Name
  3. Employer City
  4. Employer State or Province 
  5. Employer Zip or Postal Code
  6. Employer Work Phone
  7. Employer Plan Name
  8. Insurance Company Name
  9. Insurance Company ID
  10. Insurance Company Address Street Name
  11. Insurance Company City
  12. Insurance Company State or Province
  13. Insurance Company Zip or Postal Code
  14. Insurance Company Phone
  15. Insurance Company Group Name
  16. Insurance Company Group Number
  17. Insured First Name
  18. Insured Last Name
  19. Insured Relation to Patient
  20. Insured Birthdate
  21. Insured Gender
  22. Insured Social Security Number
  23. Insured Home Phone
  24. Insured Address Street Name
  25. Insured City
  26. Insured State or Province
  27. Insured Zip or Postal