DAY1 HEALTH CHRONIC MEDICATION BENEFIT APPLICATION FORM
|
|
- Eleanor Chapman
- 5 years ago
- Views:
Transcription
1 DAY1 HEALTH CHRONIC MEDICATION BENEFIT APPLICATION FORM Please complete this applica on form as follows: The member of the plan must fill in all personal and membership details in Sec on 1 & 2. Please make sure you complete both thee sec ons in full, in order to effec vely process your applica on. The doctor must fill in all medical informa on required in Sec on 3 & 4 of the applica on form. PLEASE FAX OR YOUR APPLICATION TO: Fax: chronic@1doctor.co.za SECTION 1: PRINCIPAL MEMBER INFORMATION. Surname Ini als Title Prof Dr Mr Mrs Miss Ms Mast Iden ty Number Date of Birth Membership Number Medical Aid Plan Op on 1 Employer Where would you like your medicine delivered? Code Address Tel No Home Work Cell SECTION 2: IMPORTANT PATIENT INFORMATION. Surname (if different) Title Prof Dr Mr Mrs Miss Ms Mast First Names
2 Date of Birth Tel No Home Cell Iden ty Number Work Rela onship to Member Gender M F Dependant Code Mass (kg) Height (cm) Do you smoke? Y N If yes, how many cigare es a day? How long have you smoked for? Do you consume alcohol? Y N If Yes, state type, quan ty and frequency If you have any chronic medica on queries, please contact the 1Doctor Chronic Helpdesk at Funding from the Chronic Medication Benefit is subject to clinical entry criteria, the medication acquisition rules and formulary determined by One Doctor health (Pty) Ltd and agreed to by the scheme. Please Note: ONE DOCTOR HEALTH (PTY) LTD adopts a medication reimbursement policy adhering to the single exit pricing structure for all generic and brand name medication. This policy will be implimented at all points of service across all benefit plans and no exception shall be made except where prior authorisation has been obtained from ONE DOCTOR HEALTH (PTY) LTD. Should non-preferred medication be required to treat an approved chronic condition, your GP is required to give motivation for this medication via our Medication Appeals Procedure. Medication not pre-authorised as chronic by ONE DOCTOR HEALTH (PTY) LTD may be eligible for reimbursement from the Chronic Medication Benefit. I hereby give permission for the GP to state my diagnoses and other relevant clinical informa on on this form. By applying for the Chronic Medica on Benefit, I agree tat my condi on my be subject to disease management interven ons. Signed Principal Member Pa ent (unless a Minor) Date
3 SECTION 3: RULES APPLICABLE TO CHRONIC MEDICATION BENEFIT (CMB) 1. All personal and medical details must be submi ed accurately by the GP and the pa ent where specifically requested. 2. Certain chronic condi ons require adi onal clinical informa on to be submi ed with this applica on form. Following Drug U lisa on Review, addi onal clinical informa on may also be requested. Cardiovascular Diseases: Cardiac Failure Cardiomyopathy Coronary Artery Disease Dysrhythmias Hypertension Hyperlipidaemia Addi onal Informa on - Hyperlipidaemia Exercise Smoking Lipogram Reading (Ini al/diagnos c) TCL: Risk Factors: (Please indicate where applicable) Y Y N N BP Reading BP Reading If yes, how may cigarettes a day? Date of Lipogram: LDL: HDL: Triglycerides: Angina/Myocardial Infarc on Angioplasty/Stent Cerebrovascular Accident (CVA) Family History Peripheral Vascular Disease Transient Ischaemic A ack Endocrine System: Addison s Disease Diabetes Insipidus Diabetes Mellitus 1 Diabetes Mellitus 2 Hypothyroidism Addi onal Informa on - Diabetes Mellitus 1 or 2 Fas ng Glucose: Glucose tolerance test: Respiratory Diseases: Date: Date: d d m m y Asthma Bronchiectasis Chronic Obstruc ve Pulmonary Disease (COPD) Stage 1 Stage 2 Stage 3 Ini al FEV 1 (spirometry report):
4 Auto Immune Diseases: Mul ple Sclerosis* *Please Note that confirma on of diagnosis by MRI scan is required from a Neurologist. Neurologist Practice Number: Systemic Lupus Erythematosus Rheumatoid Arthri s* *Please Note that confirma on of diagnosis by MRI scan is required from a Neurologist. Neurologist Practice Number: Gastrointes nal Diseases: Chron s Disease* Ulcera ve Coli s Neurological Diseases: Epilepsy Parkinson s Disease Ophthalmological Diseases: Glaucoma Other Diseases: Chronic Renal Disease* HIV Glomerular Filtra on rate/crea nine clearance CD4 count 3. All ONE DOCTOR HEALTH (PTY) LTD rules and exclusions will be applied during te review and authorisa on of requested chronic medica on in respect of any chronic illness. 4. Only approved General Prac oners within ONE DOCTOR HEALTH (PTY) LTD s Provider Network may apply for chronic medica on benefits on behalf of ONE DOCTOR HEALTH (PTY) LTD members on the contracted benefit plans. 5. All approved chronic medica on may only be obtained from a dispensary within the Medica on Distribu on Network authorised by All ONE DOCTOR HEALTH (PTY) LTD. 6. General Exclusions from Chronic Medica on Benefit (C.M.B) include these commonly requested medicines: Exclusions as detailed in the General Pac oner Provider Manual. 7. Access to any medica on through the C.M.B is subject to Clinical Entry Criteria and Drug U lisa on Review. 8. Diseases marked with * will exclude biological medica on. SECTION 4: CURRENT MEDICATION REQUIRED Diagnosis Medica on Name, Strength and Dosage Monthly Quan ty Dura on on Medica on Years Months Repeats
5 Are any of the above Diagnoses related to injury on duty? Y N If yes, please state: Date of injury Injury on Duty (IOD) Number: MEDICATION HISTORY IF DIFFERENT FROM CURRENT Year Diagnosis Medica on and Strength Dura on of use Pa ent Allergies: State any other illnesses the pa ent suffers from: May current medica on be subs tuted with a generic if appropriate? Y N SECTION 5: DOCTOR S DETAILS Name Prac ce Postal Address Prac ce Physical Address? Code Code
6 Tel No Speciality BHF Prac ce No Doctor s Signature Fax No Address HPC SA REG No Date
OPMED APPLICATION FORM FOR Chronic Disease List Conditions (CDL) and other Chronic Conditions
OPMED APPLICATION FORM FOR Chronic Disease List Conditions (CDL) and other Chronic Conditions ATTENDING MEDICAL PRACTICIONER TO KINDLY COMPLETE THE RELEVANT SECTIONS AND RETURN ALL PAGES TO: PO Box 8796,
More informationChronic Illness Benefit Application form 2018
Chronic Illness Benefit Application form 2018 Contact us Tel (Members): 0860 99 88 77, Tel (Health partners): 0860 44 55 66, PO Box 784262, Sandton, 2146, www.discovery.co.za. Who we are Discovery Health
More informationAPPLICATION FORM CHRONIC MEDICINE BENEFIT 2019
APPLICATION FORM CHRONIC MEDICINE BENEFIT 2019 1. Medication for all chronic conditions that are covered may be registered telephonically on 0800 132 345 (doctors and pharmacists only). 2. Alternatively,
More informationChronic Benefit Application Form Cardiovascular Disease and Diabetes
Chronic Benefit Application Form Cardiovascular Disease and Diabetes 19 West Street, Houghton, South Africa, 2198 Postnet Suite 411, Private Bag X1, Melrose Arch, 2076 Tel: +27 (11) 715 3000 Fax: +27 (11)
More informationPrescribed Minimum Benefits treatment guidelines 2013
Prescribed Minimum Benefits treatment guidelines 20 Treatment guidelines for the Prescribed Minimum Benefit chronic conditions 20 The Chronic Illness Benefit covers a limited number of tests and each for
More informationCHRONIC MEDICINE PROGRAMME GENERAL INFORMATION LETTER
RAND WATER MEDICAL SCHEME RAND WATER MEDICAL SCHEME CHRONIC MEDICINE PROGRAMME GENERAL INFORMATION LETTER LIST OF CHRONIC CONDITIONS Conditions covered under s chronic medication benefit are detailed below.
More informationSECTION A. PRINCIPAL MEMBER S DETAILS. Cell Fax ( ) SECTION B. PATIENT S DETAILS. Cell Fax ( )
CHRONIC MEDICINE BENEFIT APPLICATION FORM 2017 (To be used by Nedgroup Hospital, Traditional, Savings and Platinum members only) Please complete the application in black ink One application form must be
More informationCHRONIC MEDICINE PROGRAMME: GENERAL INFORMATION LETTER
CHRONIC MEDICINE PROGRAMME: GENERAL INFORMATION LETTER The Prescribed Minimum Benefit Chronic Disease List In terms of the Medical Scheme Act Regulations that came into effect on 1 January 2004, Medical
More informationCHRONIC TREATMENT GUIDELINES
CHRONIC TREATMENT GUIDELINES REGISTRATION OF CHRONIC CONDITIONS You can only access benefits for chronic medication, as listed below, if your prescribing/treating doctor or pharmacist registers your chronic
More informationCHRONIC MEDICINE PROGRAMME: PICK N PAY PLUS OPTION - GENERAL INFORMATION LETTER
CHRONIC MEDICINE PROGRAMME: PICK N PAY PLUS OPTION - GENERAL INFORMATION LETTER Prescribed Minimum Benefits The prescribed minimum benefits (PMBs) comprise a list of 270 conditions or group of conditions
More informationWITBANK COALFIELDS MEDICAL AID SCHEME (WCMAS) CHRONIC MEDICINE PROGRAMME GENERAL INFORMATION LETTER
WITBANK COALFIELDS MEDICAL AID SCHEME (WCMAS) CHRONIC MEDICINE PROGRAMME GENERAL INFORMATION LETTER The Prescribed Minimum Benefit Chronic Disease List In terms of the Medical Scheme Act Regulations that
More informationOverall: about 257,000 (23%) Saskatchewan residents had at least one of five chronic diseases: asthma,
P r e v a l e n c e o f A s t h m a, C O P D, D i a b e t e s, I s c h e m i c H e a r t D i s e a s e a n d H e a r t Fa i l u r e i n S a s k a t c h e w a n 2 1 2 / 1 3 R e p o r t r e l e a s e d a
More informationPrescribed Minimum Benefit Treatment Baskets 2018
Prescribed Minimum Benefit Treatment Baskets 08 Who are Glencore Medical Scheme (referred to as 'the Scheme"), registration number 5, is a non-profit organisation, registered with the Council for Medical
More informationPROFMED MEDICAL SCHEME CHRONIC MEDICINE BENEFIT GENERAL INFORMATION
PROFMED MEDICAL SCHEME CHRONIC MEDICINE BENEFIT GENERAL INFORMATION The Prescribed Minimum Benefit Chronic Disease List In terms of the Medical Schemes Act Regulations that came into effect on 1 January
More informationCHRONIC MEDICATION PROGRAMME INCLUDES PRESCRIBED MINIMUM BENEFIT CHRONIC DISEASE LIST (CDL)
CHRONIC MEDICATION PROGRAMME INCLUDES PRESCRIBED MINIMUM BENEFIT CHRONIC DISEASE LIST (CDL) A. GENERAL INFORMATION LIST OF CHRONIC CONDITIONS Conditions covered under KeyHealth s chronic medication benefit
More informationPrescribed Minimum Benefit Treatment Baskets- 2018
Prescribed Minimum Benefit Treatment Baskets- 08 Who we are The Malcor Medical Aid Scheme (referred to as the Scheme ), registration number 57, is the medical scheme that you a member of. This is a non-profit
More informationPrescribed Minimum Benefit Treatment Baskets 2018
Prescribed Minimum Benefit Treatment Baskets 08 Who we are LA Health Medical Scheme (referred to as 'the Scheme ), registration number 5, is a non-profit organisation, registered with the Council for Medical
More information20 BON ESS 17 ENTIAL
2017 This hospital plan offers rich hospital benefits with some value-added benefits. Unlimited cover up to 100% in hospital 27 PMB chronic conditions covered Network specialists paid in full in hospital
More informationPrescribed Minimum Benefit Treatment Baskets for Chronic Disease Baskets of Care 2018
Prescribed Minimum Benefit Treatment Baskets for Chronic Disease Baskets of Care 08 Who we are SAB Medical Aid (the Scheme), registration number 09, is the medical scheme. This is a nonprofit organisation,
More informationMedical Declaration Form. Important information to read before completing the form:
Administered by Medical Declaration Form Important information to read before completing the form: Pre-Existing Medical conditions Travel insurance only provides cover for emergency medical events that
More information20 HOSPITAL S 17 TANDARD
2017 This hospital plan offers extensive hospital benefits with some value-added benefits. Unlimited cover up to 100% in hospital 27 PMB chronic conditions covered Network specialists paid in full in hospital
More informationPrevalence of chronic diseases in the population covered by medical aid schemes in South Africa
Prevalence of chronic diseases in the population covered by medical aid schemes in South Africa Research and Monitoring Unit June 2014 Chairperson: Prof. Y Veriava Chief Executive & Registrar: Dr M Gantsho
More informationWe will only fund Prescribed Minimum Benefit claims should your condition be approved on the Chronic Illness Benefit
Treatment Baskets for CDL 08 Overview The Prescribed Minimum Benefit Chronic Disease List is a list of conditions which all medical schemes need to on all the plans they offer to their members. This includes
More informationHIV MANAGEMENT PROGRAMME APPLICATION FORM
Private Private Bag X82081, Bag X82081, Rustenburg, Rustenburg, 0300 0300 Tel: Tel: (014) 590 5901700 1900 Fax: Fax: 086 (014) 577 0274 591 4570 www.platinumhealth.co.za www.platinumhealth.co.za ZZGPlatinumHealthClinicalMotivation@angloamerican.com
More informationTreatment baskets for the Prescribed Minimum Benefit Chronic Disease List conditions
Treatment baskets for the Prescribed Minimum Benefit Chronic Disease List conditions 08 Treatment baskets for the Prescribed Minimum Benefit Chronic Disease List conditions Overview The Prescribed Minimum
More informationPar cipant ID #: Hello, my name is [interviewer name], and I m calling to speak with [par cipant name]. Is [par cipant name] available?
Par cipant ID #: MESA Follow up Phone Call 20: General Health Date: Acros c: / / Month Day Year INTRODUCTION Hello, my name is [interviewer name], and I m calling to speak with [par cipant name]. Is [par
More informationPreventative care: HIV test & flu vaccine Mammogram Pap smear Pneumococcal vaccine. Prostate screening
This income based entry-level plan offers basic day-to-day benefits and hospital cover using a network of doctors, providers and hospitals. What you get Basic day-to-day benefits and GP consultations with
More informationPrevalence of chronic diseases in the population covered by medical schemes in South Africa. May Research and Monitoring Unit
Prevalence of chronic diseases in the population covered by medical schemes in South Africa Research and Monitoring Unit May 2018 Prepared by: Carrie-Anne Cairncross Contributors: Mondi Govuzela, Evelyn
More informationOntario Pancreas Cancer Study (OPCS)
Ontario Pancreas Cancer Study (OPCS) The OPCS is conducted to iden fy and characterize causes of pancreas cancer, including gene c, environmental, and lifestyle factors, as well as what treatments are
More informationCHRONIC MEDICINE BENEFIT APPLICATION FORM
CHRONIC MEDICINE BENEFIT APPLICATION FORM APPLICATION INSTRUCTIONS (please complete this application as follows) 1. The application must be completed in black ink. Please print clearly and legibly. 2.
More informationBONCLASSIC. Adult dependant. Child dependant. Main member R3 648 R3 132 R 900
2017 This generous savings option offers a wide range of medical benefits, in and out of hospital. Unlimited cover up to 100% in hospital Network specialists paid in full in hospital Separate benefits
More informationIntestinal Failure Referral Form
Intestinal Failure Referral Form This form must be completed in full and emailed to UCLH.IFReferrals@nhs.net or call 07958 263178. Please complete all sections of the form. Please note that incomplete
More informationLondon Therapeu-c Tender Implementa-on: Guidance for Clinical Use. 14 January 2015
London Therapeu-c Tender Implementa-on: Guidance for Clinical Use 14 January 2015 Contents 2 3. General principles 4. Financial impact of therapeu-c tendering for branded ARVs 5. London ARV algorithm:
More informationPlease answer as many ques ons as you can before your ini al visit to EvergreenHealth Sleep Services.
Please answer as many ques ons as you can before your ini al visit to EvergreenHealth Sleep Services. Pa ent Iden fica on: Pa ent name: Date: Age: Date of birth: Who is filling out this ques onnaire? Please
More informationBMD in Family Prac ce
BMD in Family Prac ce Marc Freeman, MD FRCPC Physician Lead, Nuclear Medicine Assistant Professor Department of Medical Imaging University of Toronto marc.freeman@trilliumhealthpartners.ca 1 Disclosure
More information20 STANDARD 17 SELECT
2017 This traditional option uses a quality provider network to offer rich day-to-day benefits and hospital cover. Unlimited cover up to 100% at hospitals on the Standard Select network Rich day-to-day
More informationCompany/Group Name: Business Telephone: Fax: Option 2:
Application Form Please read through the following before completing this application form in BLOCK CAPITALS. You must disclose all material facts. Failure to do so may invalidate the Cover. A material
More informationSTANDARD. Adult dependant. Main member. Child dependant R2 998 R2 600 R 880
2017 This traditional option offers rich day-to-day benefits and comprehensive hospital cover. Unlimited cover up to 100% in hospital Network specialists paid in full in hospital Additional benefit for
More informationClinical Considera-ons of High Intensity Interval Training (HIIT)
Clinical Considera-ons of High Intensity Interval Training (HIIT) Jenna Taylor Exercise Physiologist & Dietitian The Wesley Hospital PhD Candidate The University of Queensland What is High Intensity Interval
More informationCon nued Professional Development (CPD) Scheme
Con nued Professional Development (CPD) Scheme March 2010 Background On 31 December 2008 the Postgraduate Medical and Dental Board (PGM&DB) was dissolved and its func ons were transferred to the Health
More informationHIV Programme. Overview. About some of the terms we use in this document
HIV Programme Overview This document gives you information about the Bankmed HIV Programme. It explains your cover for hospital admissions related to HIV and AIDS and how we pay for HIV medication. We
More informationCHAPTER 13. Renal Transplanta on
CHAPTER 13 Renal Transplanta on Rosnawa Yahya Hooi Lai Seong Ng Kok Peng Surya Bin Yakaob Wong Hin Seng SECTION 13.1: STOCK AND FLOW The number of new transplant pa ents decreased from 151 in 26 to its
More informationNon-Member Health Screening
Non-Member Health Screening 1390 Taylor Avenue, Winnipeg, Manitoba, R3M 3V8 Phone: 204-488-8023 / Fax: 204-488-4819 Please select Non-Member type: Adult Guest (with member) Adult Guest (without member)
More informationPRIMARY. Adult dependant. Main member. Child dependant R1 924 R1 505 R 613
2017 This traditional option offers simple day-to-day benefits and hospital cover. Unlimited cover up to 100% in hospital Separate benefit for GP consultations Network specialists paid in full in hospital
More informationHEAL Protocol for GPs and Practice Nurses
HEAL Protocol for GPs and Practice Nurses Exercise Pathway Co-ordinator Sport & Active Leisure West Offices Station Rise York YO1 6GA Telephone: 01904 555755 Email: angela.shephard@york.gov.uk 1 P a g
More informationDancing with the Docs 2015
Dr. Alison Dugan Dr. Carol Gonsalves Dr. Ken Kobayashi Dr. Anne McCarthy Dr. Rob Beanlands Dr. Phil Wells Dr. Kayvan Amjadi Dr. José Pereira Dr. Ruchi Murthy Dr. Michael Schlossmacher The Department of
More informationSuccessful School- based Asthma Programs
Successful School- based Asthma Programs Missouri Asthma Preven on and Control Program Peggy Gaddy, RRT, MBA peggy.gaddy@health.mo.gov (573) 522-2876 The tle is not accurate. Let s change it. Successful
More informationPatient Information. Patient Name: DOB: Last First M.I. Home Address: City: State: Zip: Home Phn: Cell Phn: Alt. Phn: SSN:
Dr. Alvin Huang, M.D., F.A.C.E. 1650 W. Rosedale St. Suite 301, Fort Worth TX 76104 (P) 817-259-4333 (F) 817-820-0303 Patient Information Patient Name: DOB: Last First M.I. Home Address: City:_ State:
More informationLOW-DOSE CT BONE DENSITOMETRY FOR ROUTINE AND SPECIALIST USE
LOW-DOSE CT BONE DENSITOMETRY FOR ROUTINE AND SPECIALIST USE Clinically superior BMD solutions for physicians DXA equivalent hip measurements Innovative clinical trials & research applications mindwaysaustralia.com.au
More informationPreventative care: HIV test & flu vaccine. Full lipogram Mammogram Pap smear Pneumococcal vaccine. Prostate screening. Bone density screening
This first-class savings plan offers ample savings, an above threshold benefit and extensive hospital cover. What you get R R Rich savings and unlimited above threshold benefit R1 220 antenatal classes
More informationGP Exercise Referral
GP Exercise Referral Course Guide Thank for you your interest in the GP Exercise Referral course with Amac. Within this course guide, you will find information on the different parts of the course. If
More informationJuly 5th-7th, 2016 Thompson Rivers University, Kamloops
Speak Out Loud Conference July 5th-7th, 2016 Thompson Rivers University, Kamloops Who? Members 13 to 19 years old before January 1st When? July 5th-7th 2016 Where? Thompson Rivers University, Kamloops
More informationchapter 1 chapter 2 chapter 3 chapter 4
Summary Summary Type 2 diabetes mellitus (T2DM) has reached epidemic propor ons worldwide. Mortality rates in T2DM pa ents are increased and cardiovascular disease, in par cularly heart failure, is a
More informationHIVCare Programme 2017
HIVCare Programme 2017 Who we are LA Health Medical Scheme (referred to as 'the Scheme"), registration number 1145, is a non-profit organisation, registered with the Council for Medical Schemes. Discovery
More informationPATIENT INFORMATION. Last Name First Name MI. Address. City State Zip. Cell Phone _( ) Home Phone _( ) May we contact you by ?
PATIENT INFORMATION date: Last Name First Name MI Address City State Zip Cell Phone _( ) Home Phone _( ) Email May we contact you by email? Yes No Date of Birth Age Marital Status Patient s Occupation
More informationKEY UNDERWRITING CONSIDERATIONS
ENHANCED ANNUITY KEY UNDERWRITING CONSIDERATIONS Discussing health issues tends to be an emotive subject and in general people tend to downplay their medical conditions. The aim of this guide is to support
More information20 BON CO 17 MPREHENSIVE
2017 This first-class savings plan offers ample savings, an above and extensive hospital cover. Unlimited cover up to 300% in hospital Cancer benefit of R556 700 including benefit for specialised drugs
More informationNew indicators to be added to the NICE menu for the QOF and amendments to existing indicators
New indicators to be added to the for the QOF and amendments to existing indicators 1 st September 2015 Version 1.1 This document was originally published on 3 rd August 2015, it has since been updated.
More informationThis page is for information. Do not submit.
This page is for information. Do not submit. AISH Application - Part B Medical Report Information for Physicians Your patient (the applicant) is applying for the Assured Income for the Severely Handicapped
More information60 conditions covered. R chronic benefit per family Comprehensive medicine list. Savings
BONCOMPREHENSIVE SAVINGS OPTION This first-class savings plan offers ample savings, an above threshold benefit and extensive hospital cover. In-hospital, consultations & treatment at 300% R589 000 cancer
More informationSec on 1 Demographic Informa on
The Priority Care Center A Program of the Humboldt IPA Primary Care Physician: Sec on 1 Demographic Informa on How were you referred: Name (Last, First, M.I.): A.K.A.: Date of Birth: Mailing Address: /
More informationGP Exercise Referral
GP Exercise Referral Course Guide Thank for you your interest in the GP Exercise Referral course with Amac. Within this course guide, you will find information on the different parts of the course. If
More informationNATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE General practice Indicators for the NICE menu
NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE General practice Indicators for the NICE menu Indicator area: Pulse rhythm assessment for AF Indicator: NM146 Date: June 2017 Introduction There is evidence
More informationWelcome to the Healthplex!
Welcome to the Healthplex! Program Please check program that applies to you. If unsure, please ask our staff. Aftercare Employee Health Pulmonary Rehab Lung Gym Cardiac Rehab Health Improvement Prenatal/Post-Partum
More informationOver. Signature of Patient/Parent/Guardian: Date: / / Date: / / Patient s Name: For ADULT Patients : Employer: Address: Occupation:
Date: / / Patient s Name: Address: Preferred Home: ( ) - Work: ( ) - Cell: ( ) - Text Message Reminders : Yes No Social Security #: Date of Birth: - - / / For ADULT Patients : Employer: Occupation: Spouse
More informationExercise Referral Form
Exercise Referral Form To be completed by the referring Health Professional All patient data will be kept securely and in accordance with Data Protection guidelines Patient Details: Title: Mr/Mrs/Ms/Miss/Other:
More informationANAESTHESIA QUESTIONNAIRE: (TO BE COMPLETED BY THE PATIENT (POSSIBLY TOGETHER WITH THE GP))
Version No. 1.0 Valid from dec 2016 Document number DC 491 Unit Anaesthesia ANAESTHESIA QUESTIONNAIRE: (TO BE COMPLETED BY THE PATIENT (POSSIBLY TOGETHER WITH THE GP)) Together with your treating physician,
More informationAdult Pre Participation Screening and Exercise Prescription Practicum
Adult Pre Participation Screening and Exercise Prescription Practicum Objectives of this exercise: To administer pre participation screening and risk stratification for clients To write an appropriate
More informationSUMMARY OF CHANGES TO QOF 2017/18 - ENGLAND CLINICAL
SUMMARY OF CHANGES TO QOF 2017/18 - ENGLAND KEY No change Retired/replaced Wording and/or timeframe change Point or threshold change Indicator ID change 1/17 QOF ID 17/18 QOF ID NICE ID Indicator wording
More informationAdditional details about you What is your ethnic group? Name of next of kin \ Emergency contact
Thank you for applying to join The Hedges Medical Centre. We would like to gather some information about you and ask that you fill in the following questionnaire. You don t have to supply answers to all
More informationC O P E. Milwaukee County Opioid Related Overdose Report MILWAUKEE COMMUNITY OPIOID PREVENTION EFFORT
Milwaukee County Opioid Related Overdose Report 2012 2016 MILWAUKEE C O P E COMMUNITY OPIOID PREVENTION EFFORT For addi onal informa on or if you have ques ons about the data presented in this report,
More informationInitial Patient Health Assessment Form
Initial Patient Health Assessment Form General Information: Patient Name:, Date: / /20 Patient s Address:. City:, State:, Zip Code: Home Phone #: - -, Work Phone #: - -, Cell #: - - E-mail address:, Date
More information17/18 Threshold 18/19 Points 18/19. Points NO CHANGE NO CHANGE NO CHANGE
SUMMARY OF CHANGES TO QOF 2018/19 - ENGLAND 18-19 QOF005 KEY No change Retired/replaced Wording and/or timeframe change Point or threshold change Indicator ID change 17/18 QOF ID 18/19 QOF ID NICE ID Indicator
More informationATTENDING PHYSICIAN'S STATEMENT MULTIPLE SCLEROSIS
ATTENDING PHYSICIAN'S STATEMENT MULTIPLE SCLEROSIS A) Patient s Particulars Name of Patient Gender NRIC/FIN or Passport No. Date of Birth (ddmmyyyy) B) Patient s Medical Records 1) Please state over what
More informationThree Rivers Ayurveda-Patient Medical History
Three Rivers Ayurveda-Patient Medical History Name: DOB: Date: As a new patient, we first would like you to answer the questions below so that we can get an idea of your past medical history. On page 5
More informationFrank X. Pedlow, Jr., MD, PC Spine Information Intake Form
Frank X. Pedlow, Jr., MD, PC Spine Information Intake Form Please print all information. All blanks must be filled to allow us to serve you quickly and efficiently. Thank you for your cooperation. Patient
More informationPOTENTIAL LINKAGES BETWEEN THE QUALITY AND OUTCOMES FRAMEWORK (QOF) AND THE NHS HEALTH CHECK
POTENTIAL LINKAGES BETWEEN THE QUALITY AND OUTCOMES FRAMEWORK (QOF) AND THE NHS HEALTH CHECK Author: CHARLOTTE SIMPSON, SPECIALTY REGISTAR PUBLIC HEALTH (ST3), CHESHIRE EAST COUNCIL/MERSEY DEANERY SUMMARY
More informationTHIS FORM IS TO BE COMPLETED BY CANDIDATE.
THIS FORM IS TO BE COMPLETED BY CANDIDATE. Information requested on this Candidate Pre-Placement Health Questionnaire ( Questionnaire ) is collected pursuant to Saudi Arabian Oil Company ( Saudi Aramco
More informationARTHRITIS & RHEUMATOLOGY OF GA, PC
ARTHRITIS & RHEUMATOLOGY OF GA, PC GARY MYERSON, MD PAUL SUTEJ, MD PAULA TANASA, MD ANNA ADAMS, PA-C CASHELLE ROSE, PA-C NEW PATIENT REGISTRATION FORM (Please Print) Patient Information Patient s last
More informationOphthalmologist/Optometrist/Low Vision Clinic Report. 1.1 Title: (Mr/Mrs/Miss, etc) Surname: Full Names:. 1.4 Physical Address:.
OPTIMA COLLEGE COMPUTER SKILLS PROGRAMME APPLICATION FORM PLEASE NOTE: Incomplete applications will not be considered. Please ensure that the following are attached: Medical Report Ophthalmologist/Optometrist/Low
More informationMeasuring Long-Term Conditions in Scotland - A summary report
Measuring Long-Term Conditions in Scotland - A summary report Introduction This summary report provides insight into: What are the most common long-term conditions in Scotland? What is the population prevalence
More informationFairfield County Bariatrics & Surgical Specialists, P.C. Neil R. Floch, M.D. Abraham Fridman, D.O. Craig L. Floch, M.D.
Fairfield County Bariatrics & Surgical Specialists, P.C. Neil R. Floch, M.D. Abraham Fridman, D.O. Craig L. Floch, M.D. 148 East Avenue, Suite 3-A 2 Trap Falls Road, Suite 100 Norwalk, CT 06851 Shelton,
More informationBrewster Chiropractic Michael B. Singleton DC, MS, CNS, CSCS
Michael B. Singleton DC, MS, CNS, CSCS How did you hear about this office? Today s Date / / Signature of Patient Patient Title: (check one) Mr. Mrs. Ms. Miss Dr. Prof. Rev. First Name Preferred to be called
More informationNew Patient Questionnaire
New Patient Questionnaire Welcome to Mass General/North Shore Cardiology. Please fill out the following questionnaire, answering each question to the best of your ability. The information will assist your
More informationSchedule of. Applicable 1 January 2019 to 31 December Version 2 INTELLIGENT MEDICAL AID FOR POST-GRADUATES
Schedule of 2019 Applicable 1 January 2019 to 31 December 2019. Version 2 Please read in conjunction with the Information Guide and Rules of the Scheme available at www.profmed.co.za or by calling 0860
More informationConclusions: The Voice of the Donor for a Cure. August 5, 2013 August 5, Peter Miselis, CFA
Voice of the Donor for a Cure The Voice of the Donor for a Cure Juvenile Diabetes Cure Alliance Peter Miselis, CFA Director of Research Analysis 212.308.7433 pdm@thejdca.org Founda onal Data Report: The
More informationPATIENT INTAKE FORM Health & Wellness
PATIENT INTAKE FORM Health & Wellness GRAFFEO CHIROPRACTIC CLINIC Joseph Graffeo, DC, PC Date: ABOUT YOU 16248 NE Glisan St Portland, OR 97230 First Name Last Name Middle Name Email Address Street Address
More informationENROLMENT FORM. Title: First Name: Surname: Postal Address: Postcode: Emergency Contact: Relationship: Phone: What is your main fitness goal?
ENROLMENT FORM Personal Information Title: First Name: Surname: Date of Birth: Sex: Female Male Postal Address: Postcode: Phone: Home: Work: Mobile: Email: Preferred method of contact: Letter Phone Email
More informationEvolve180 / Ideal Northwest Health Profile
Evolve180 / Ideal Northwest Health Profile ABOUT YOU First Name: Last Name: Address: City: State: Zip: Phone: Email: Date of Birth: Age: Height: Occupation: How did you find out about our program? Marital
More informationThe contractor establishes and maintains a register of patients with AF
Atrial Fibrillation The contractor establishes and maintains a register of patients with AF G5731 Those patients with AF in whom there is a record of CHADS2 score of 1, the % of patients who are currently
More informationMETHOTREXATE. When is methotrexate chosen as a treatment option and how is the dose calculated?
Brief background to methotrexate The immune system is important in figh ng infec ons, but some mes cells of the immune system can become over ac ve in the body s own ssues and cause long term inflamma
More informationPersonal Training Health Screening Questionnaire
RC Health and Fitness, LLC. 10350 Ironbridge Road Chester, VA 23831 (804)248-0222 Personal Training Health Screening Questionnaire Personal Information Today s date: Title: O DR. O Mr. O Mrs. O Ms. Name:
More information14/15 Threshold 15/16 Points 15/16. Points. Retired Replaced by NM82/AF007. Replacement NO CHANGE
SUMMARY OF CHANGES TO QOF 2015/1 - ENGLAND KEY No change Retired/replaced Wording and/or change Point or threshold change Indicator ID change 14/15 QOF ID 15/1 QOF ID NICE ID Indicator wording Changes
More informationSection 1 Section 2 Section 3 Section 4 Section 5 Section 6 Section 7 Section 8 Section 9
Medical Conditions Questionnaire Complete the appropriate section(s) only after filling in the Proposal Form Lutine Assurance Services Limited Full name: If you suffer, or have suffered at any time, from
More informationQualification Form Instructions
Qualification Form Instructions Congratulations on taking steps toward maintaining or improving your health! The Blue Cross Blue Shield of Michigan qualification form is enclosed for you and your physician
More informationBOTLHE MEDICAL AID SCHEME - APPLICATION FORM
What you must do 1. 2. 3. 4. 5. Once you have submitted your application form, here is what will happen: - If any details are missing or if we need more information for underwriting purposes, we will contact
More informationDiabetes Program Enrollment Questionnaire Please complete this questionnaire with as much information as possible
Diabetes Program Enrollment Questionnaire Please complete this questionnaire with as much information as possible Demographic Information Name: Insurance ID#: Address: City/State/Zip Code: Date of Birth:
More information2013 Research Chairs: Visit for more informa on about this exci ng learning opportunity!
The Interna onal Community Correc ons Associa on presents the 2nd Annual Conference in the What Ma ers Series REGISTER TODAY! September 9 12, 2013 ICCA has expanded its successful two decades of "What
More informationInternational IBD Genetics Consortium
International IBD Genetics Consortium PRED4 Case Report Form Please stick study label here On completion, please return to: Claire Bewshea IBD Pharmacogenetics Research Office Ground Floor, Child Health
More informationKinevia / Kinevia Duo. Product Line introduc-on
Kinevia / Kinevia Duo Product Line introduc-on The posi.ve effect of Kinevia! Ac.vate muscles. Stabilize joints! Maintain and build muscles! Mobilize residual muscle strength! Regulate muscle tone and
More information