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SUNY Upstate University Hospital
750 E Adams Street, Syracuse, NY 13210
(315) 464-4320
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Email
Guarantor Number (Box 2)
Medical Record Number
Guarantor ID
Guarantor First Name
Guarantor Last Name
First Name
Last Name
Middle
Guarantor Birth Date
Patient's date of birth (MM/DD/YYYY).
Phone Number
5-digit Zip
Statement Number
Statement Date
Amount Due
Dynamic Field 1
Dynamic Field 2
Dynamic Field 3
Dynamic Field 4
ProviderAlias
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