Make Enrollment Form From Pokitdok Enrollment API

[allenbyerly]

@enrollment = { action: "Change", dependents: [], master_policy_number: "ABCD012354", payer: { tax_id: "654456654" }, purpose: "Original", reference_number: "12456", sponsor: { tax_id: "999888777" }, subscriber: { address: { city: "CAMP HILL", county: "CUMBERLAND", line: "100 MARKET ST", line2: "APT 3G", postal_code: "17011", state: "PA" }, benefit_status: "Active", benefits: [ { begin_date: "Sat Jun 1 00:00:00 1996", benefit_type: "Health", coordination_of_benefits: [ { group_or_policy_number: "890111", payer_responsibility: "Primary", status: "Unknown" } ], late_enrollment: false, maintenance_type: "Addition" }, { begin_date: "Sat Jun 1 00:00:00 1996", benefit_type: "Dental", late_enrollment: false, maintenance_type: "Addition" }, { begin_date: "Sat Jun 1 00:00:00 1996", benefit_type: "Vision", late_enrollment: false, maintenance_type: "Addition" } ], birth_date: "Fri Aug 16 00:00:00 1940", contacts: [ { communication_number2: "7172341240", communication_type2: "Work Phone Number", primary_communication_number: "7172343334", primary_communication_type: "Home Phone Number" } ], eligibility_begin_date: "Thu May 23 00:00:00 1996", employment_status: "Full-time", first_name: "JOHN", gender: "Male", group_or_policy_number: "123456001", handicapped: false, last_name: "DOE", maintenance_reason: "Active", maintenance_type: "Addition", member_id: "123456789", middle_name: "P", relationship: "Self", ssn: "123456789", subscriber_number: "123456789", substance_abuse: false, tobacco_use: false }, trading_partner_id: "MOCKPAYER" }