| 1 | Record ID | AN | Y | 7 | 7 | IMPPN11 |
| 2 | Transaction ID | AN | Y | 32 | 32 | |
| 3 | Merchant ID | AN | Y | 1 | 50 | |
| 4 | Store ID | AN | Y | 1 | 50 | |
| 5 | Terminal ID | AN | Y | 1 | 50 | |
| 6 | Message Date | DT | Y | 8 | 8 | YYYYMMDD |
| 7 | Total Charge | DEC | Y | | | 0 |
| 8 | Card Type | AN | N | 1 | 25 | Values include: ”PRIVATE LABEL,” “VISA,” “OTHER,” “MASTERCARD,” “AMEX,” “DISCOVER” |
| 9 | Patient Last Name | AN | N | 1 | 50 | |
| 10 | Patient First Name | AN | N | 1 | 50 | |
| 11 | Patient Middle Name | AN | N | 1 | 50 | |
| 12 | Patient Birthdate | DT | N | 8 | 8 | YYYYMMDD |
| 13 | Patient Account Number | AN | N | 1 | 50 | |
| 14 | Patient Medical Record Number | AN | N | 1 | 50 | |
| 15 | Patient Street | AN | N | 1 | 150 | |
| 16 | Patient Street 2 | AN | N | 1 | 150 | |
| 17 | Patient City | AN | N | 1 | 50 | |
| 18 | Patient State | AN | N | 1 | 30 | |
| 19 | Patient Zip | AN | N | 1 | 15 | |
| 20 | Patient Service Begin Date | DT | N | 8 | 8 | YYYYMMDD |
| 21 | Patient Service End Date | DT | N | 8 | 8 | YYYYMMDD |
| 22 | Additional Info 1 | AN | N | 1 | 100 | |
| 23 | Additional Info 2 | AN | N | 1 | 100 | |
| 24 | Additional Info 3 | AN | N | 1 | 100 | |
| 25 | Additional Info 4 | AN | N | 1 | 100 | |
| 26 | Additional Info 5 | AN | N | 1 | 100 | |
| 27 | Additional Info 6 | AN | N | 1 | 100 | |
| 28 | SaveOnFileTransactionID | AN | Y | 32 | 32 | Use for real-time card transactions |
| 29 | Payment Plan Type | AN | Y | 1 | 50 | Values include: Save on File, Recurring, Installment |
| 30 | Initial Payment Amount | DEC | N | | | 0 |
| 31 | Frequency | AN | N | 1 | 50 | Values include: Weekly, Twice Monthly, Monthly, Quarterly, Annually |
| 32 | Payment Amount | DEC | N | | | 0 |
| 33 | Plan Start Date | DT | N | 8 | 8 | YYYYMMDD |
| 34 | Plan End Date | DT | N | 8 | 8 | YYYYMMDD |
| 35 | Next Transaction Date | DT | N | 8 | 8 | YYYYMMDD |
| 36 | Next Transaction Amount | DEC | N | | | 0 |
| 37 | Payments to Date | AN | N | | | 0 |
| 38 | Total Paid to Date | DEC | N | | | 0 |
| 39 | Remaining Payments | AN | N | | | 0 |
| 40 | Remaining Balance | DEC | N | | | 0 |
| 41 | Plan Status | AN | Y | | | Values include: Active, Inactive, Complete |
| 42 | Additional Code 1 | AN | N | 1 | 50 | |
| 43 | Additional Code 2 | AN | N | 1 | 50 | |
| 44 | Additional Code 3 | AN | N | 1 | 50 | |
| 45 | Additional Code 4 | AN | N | 1 | 50 | |
| 46 | Additional Code 5 | AN | N | 1 | 50 | |
| 47 | Additional Code 6 | AN | N | 1 | 50 | |
| 48 | Additional Code 7 | AN | N | 1 | 50 | |
| 49 | Additional Code 8 | AN | N | 1 | 50 | |
| 50 | Additional Code 9 | AN | N | 1 | 50 | |
| 51 | Additional Code 10 | AN | N | 1 | 50 | |
| 52 | Additional Code 11 | AN | N | 1 | 50 | |
| 53 | Additional Code 12 | AN | N | 1 | 50 | |
