| 1 | Record ID | "IMPTI10" | Y | 7 | 7 | |
| 2 | Merchant ID | AN | Y | 1 | 50 | The unique ID associated with your merchant processing account, which will be given by your Implementation Manager. |
| 3 | Store ID | AN | Y | 1 | 50 | Default value is 1. |
| 4 | Terminal ID | AN | Y | 1 | 50 | May differ by location ( at no extra cost to the provider ) to enhance security and reporting. |
| 5 | Payment Transaction Type | AN | Y | 1 | 35 | Supported values are: "CreditCard,” "eCheck" and "Cash". |
| 6 | Payment Transaction Action | AN | Y | 1 | 35 | Supported values are: "AuthCapt" and "Credit". |
| 7 | Transaction Date | DT | Y | 14 | 14 | Date/time in CCYYMMDDHHMMSS format. |
| 8 | Amount | DEC | Y | | | Always positive decimal value. Payment Transaction action = "Credit" should cause this field to be interpreted as a refund. |
| 9 | Card Type | AN | O | 1 | 25 | This field is returned when the transaction type is CreditCard. Values include: "VISA,” "MC,” "AMEX,” "DISCOVER" and "OTHER". |
| 10 | Check AccountType | AN | O | 1 | 50 | Checking, Saving and Business. |
| 11 | Card/Check Number | AN | Y | 1 | 50 | Truncated CardNumber or check number. |
| 12 | Card Expiration Date | AN | S | 6 | 6 | Applicable for credit card only. Expiration date in the MMCCYY format. |
| 13 | Check Routing Number | AN | S | 10 | 10 | When Payment Transaction action is eCheck, this field is required. |
| 14 | Authorization Number | AN | O | 1 | 50 | |
| 15 | Is Swiped | AN | O | 1 | 1 | Supported values are: "Y" or "N" indicating whether the card/check was swiped or not. |
| 16 | Account/Card Holder Name | AN | O | 1 | 150 | |
| 19 | Account/Card Holder Address 1 | AN | O | 1 | 150 | |
| 20 | Account/Card Holder Address 2 | AN | O | 1 | 150 | |
| 21 | Account/Card Holder City | AN | O | 1 | 50 | |
| 22 | Account/Card Holder State | AN | O | 2 | 2 | |
| 23 | Account/Card Holder ZipCode | AN | O | 5 | 15 | |
| 24 | Account/Card Holder Country | AN | O | 1 | 50 | |
| 25 | Account/Card Holder Phone # | AN | O | 1 | 13 | Field in xxx-xxx-xxxx format. |
| 26 | Account/Card Holder Email Address | AN | O | 1 | 50 | |
| 27 | Patient LastName | AN | O | 1 | 50 | |
| 28 | Patient FirstName | AN | O | 1 | 50 | |
| 29 | Patient MiddleName | AN | O | 1 | 50 | |
| 30 | Patient Account Number | AN | O | 1 | 50 | |
| 31 | Patient Address 1 | AN | O | 1 | 150 | |
| 32 | Patient Address 2 | AN | O | 1 | 150 | |
| 33 | Patient City | AN | O | 1 | 50 | |
| 34 | Patient State | AN | O | 1 | 30 | |
| 35 | Patient ZipCode | AN | O | 1 | 15 | |
| 36 | Patient Country | AN | O | 1 | 50 | |
| 37 | Patient Phone # | AN | O | 1 | 13 | Field in xxx-xxx-xxxx format. |
| 38 | PatientServiceBeginDate | DT | O | 14 | 14 | |
| 39 | PatientServiceEndDate | DT | O | 14 | 14 | |
| 40 | Patient Medical Record # | AN | O | 1 | 50 | |
| 41 | Patient DOB | DT | O | 14 | 14 | In CCYYMMDD format. |
| 42 | Status | AN | O | 20 | 20 | Defaulted to approved. Possible statuses: settled, denied, voided or approved. |
| 43 | AdditionalInfo1 | AN | O | 1 | 100 | User-defined fields to be captured with the payment transaction. |
| 44 | AdditionalInfo2 | AN | O | 1 | 100 | See AdditionalInfo1 comments. |
| 45 | AdditionalInfo3 | AN | O | 1 | 100 | See AdditionalInfo1 comments. |
| 46 | AdditionalInfo4 | AN | O | 1 | 100 | See AdditionalInfo1 comments. |
| 47 | AdditionalInfo5 | AN | O | 1 | 100 | See AdditionalInfo1 comments. |
| 48 | AdditionalInfo6 | AN | O | 1 | 100 | See AdditionalInfo1 comments. |
| 49 | User | AN | O | 1 | 100 | If not included, user will be set to PTI. |
