Guideline Request Form Instructions
|
|
|
- Clara Lyons
- 5 years ago
- Views:
Transcription
1 Guideline Instructions We at Office Ally realize that the process of creating Guidelines can be time consuming. In an effort to help speed up the process we have implemented a new solution. Now, instead of you creating your guideline(s), we will do it for you. While we will do the work of creating the guidelines we will still need information from you. The following Guideline (pages 2 to 14 of this document) is a full list of all items that can appear in your guideline(s). Each section has a box for you to list all of the statements and responses that fit within that category that you want to be displayed as clickable links in your progress note(s). The boxes include a breakdown by Question and Answer (Q1, A1, Q2, A2, etc.). All separate responses within one category (i.e. separate possible answers) need to be separated by a semi colon (;) in order for us to know where to break up the text when inserting it into your guidelines. Here are a couple of examples on how to best complete these fields: Example 1: Q1: How long have you been experiencing these issues? A1: 1 day; 2 days; 3 days; 4 days; 5 days; 6 days; 1 week; 2 weeks; 3 weeks; 1 month Q2: Have you experienced these issues in the past? A2: Yes; No; Occasionally; Sometimes Example 2: You are asking the patient what symptoms they are currently experiencing in order to complete the Chief Complaints section. In this situation you do not want any questions listed, just simply a list of possible chief complaints. Any time in which you don t have a statement to add and simply want to include the Patient s possible responses simply fill in the A line only. Q1: A1: Coughing; Sneezing; Congestion Q2: A2: Pain in; right; left; arm; leg; foot; ear Once you have successfully completed the attached document please send it via to guidelines@officeally.com. If you have any questions about this document and how to complete it please call Technical Support at (866) opt. 2. Once Office Ally receives your request we will begin building your guidelines. Please be aware that by submitting this to us you are authorizing us to add it to our Guideline Library. We will make every effort to complete all guideline requests within 2 weeks. Once the guideline(s) have been created an Office Ally representative will contact you to obtain the password for the account username provided. Once we have the password we will log into your account and insert the guideline. Upon inserting the guideline into your account an Office Ally representative will send an to the address on file stating that your guideline is now available in your account.
2 Office Ally Account Username: Date: Specialty: Guideline Name: SUBJECTIVE Chief Complaints History of Present Illness Subjective Custom Field #1: Subjective Custom Field #2: Past History: Medical History 1 P age
3 Past History: Surgical History Past History: Gynecological History Past History: Family History Past History: Social History Allergies Immunization 2 P age
4 Current Medications Subjective Custom Field #3: Subjective Custom Field #4: Review of System: Constitutional Review of System: Head Review of System: Eyes 3 P age
5 Review of System: Ears Review of System: Nose Review of System: Mouth Review of System: Throat Review of System: Neck Review of System: Cardiovascular Review of System: Respiratory 4 P age
6 Review of System: Gastrointestinal Review of System: Genitourinary Review of System: Musculoskeletal Review of System: Integumentary (Skin and/or Breast) Review of System: Neurological Review of System: Psychiatric Review of System: Endocrine 5 P age
7 Review of System: Hematologic/Lymphatic Review of System: Allergic/Immunologic ROS Custom Field #1: ROS Custom Field #2: ROS Custom Field #3: ROS Custom Field #4: 6 P age
8 OBJECTIVE Objective Physical Examination: Constitutional Physical Examination: Eye Physical Examination: Ears, Nose, Mouth, and Throat Physical Examination: Ear Past History: Gynecological History Physical Examination: Nose 7 P age
9 Physical Examination: Mouth Physical Examination: Throat Physical Examination: Neck Physical Examination: Lungs Physical Examination: Respiratory Physical Examination: Cardiovascular 8 P age
10 Physical Examination: Chest/Breasts Physical Examination: Heart Physical Examination: Gastrointestinal (Abdomen) Physical Examination: Genitourinary Physical Examination: Lymphatic Physical Examination: Musculoskeletal Physical Examination: Skin 9 P age
11 Physical Examination: Extremities Physical Examination: Neurological/Psychiatric Physical Examination: Head/Face PE Custom Field #1: PE Custom Field #2: PE Custom Field #3: 10 P age
12 PE Custom Field #4: Test Result Exams: ECG Test Result Exams: Image Test Result Exams: Labs ASSESSMENT & PLAN Assessment Notes Assessment Custom Field #1: 11 P age
13 Assessment Custom Field #2: Procedure Notes: Plan Notes Patient Instructions / Follow Up Patient / Parent or Guardian Comments Plan Custom Field #1: 12 P age
14 Plan Custom Field #2: Plan Custom Field #3: Plan Custom Field #4: 13 Page
Practical E/M Audit Form: Initial Outpatient Visit (p.1)
Patient: Name: Chart #: Date of visit: / / Reviewed by: Date of review: / / Practical E/M Audit Form: Initial Outpatient Visit (p.1) Medical History Review Select the level corresponding to lowest of the
Appendix I: E/M CodeBuilder
Appendix I: E/M CodeBuilder For use with CMS 1997 Documentation Guidelines for Evaluation & Management Coding, which is located on the Student Companion Web Site at www.cengagebrain.com. CMS also published
HIV/AIDS Care: The Service (CPT) Code Evaluation and Management Series 1
HIV/AIDS Care: The Service (CPT) Code Evaluation and Management Series 1 Prepared By: Stacey L. Murphy, MPA, RHIA, CPC AHIMA Approved ICD-10-CM/ICD-10-CM Trainer Learning Outcomes Explain the importance
ChiroCredit.com / OnlineCE.com presents Documentation 101 Part 5 of 10 Instructor: Paul Sherman, DC
Online Continuing Education Courses www.onlinece.com www.chirocredit.com ChiroCredit.com / OnlineCE.com presents Documentation 101 Part 5 of 10 Instructor: Paul Sherman, DC Important Notice: This download
WELCOME TO OUR OFFICE
WELCOME TO OUR OFFICE Name: Today s Date: First Middle Last Gender: Male Female Date of birth: Age: Home Address: City: State: Zip: Home Phone:( ) Cell Phone:( ) Occupation: SSN: Employer: Time of employment
COA Advanced Practice Provider Call
COA Advanced Practice Provider Call Tuesday, September, 19 th, 12:30 pm ET 2015 Community Oncology Alliance 1 CAPP Co-Chairs: Sara Pearce, NP-C, Cancer Care of WNC spearce@cancercareofwnc.com Diana Youngs,
Dear Mercy Cancer Center Radiation Oncology Patient
Dear Mercy Cancer Center Radiation Oncology Patient Welcome to our Department. In order to complete our records, and enable our physicians to ensure that your questions are fully addressed, we appreciate
New Patient Packet. Patient Name: DOB: Age: Address: City: State: Zip: Address: City: State: Zip: Name: Address: Phone: Fax:
New Patient Packet Patient Name: DOB: Age: Sex: Male / Female Height: Weight: PHYSICIAN CARE Primary Care Physician: Address: City: State: Zip: Phone: Fax: Referring Physician (if different from PCP):
SARAH VLACH, MD TYLER HEDIN, MD JUDY GOOCH, MD
Name: Height: Birthdate: Weight: Chief Complaint: What is the reason for your appointment? (please describe why you are here) Medications: Please list ALL medications with dosages you are currently taking,
How to Code Correctly for E/M Services (1997 Guidelines)
How to Code Correctly for E/M Services (1997 Guidelines) Phillip Ward, DPM CPT Editorial Board Advisor for Foot and Ankle Former CPT Assistant Editorial Board Member Past President, APMA General Principles
New Patient History. Name: DOB: Sex: Date: If yes, give the name of the physician who did your evaluation or ordered your tests:
New Patient History Name: DOB: Sex: Date: Chief Complaint: 1. Give a brief description of the problem you are seeking treatment for today: 2. Have you been evaluated for this problem or had any tests for
10/17/2013. Billing and Coding in Long Term Care: Keeping the Wolves at Bay. Disclosure
Billing and Coding in Long Term Care: Keeping the Wolves at Bay Maine Medical Directors Association Annual Conference October 11, 2013 Alva S Baker, MD, CMD-R Disclosure Dr. Baker has indicated that he
Medical History Form. Patient Information. Medical History. Middle Initial: Date: Salutation: Sex: First Name: Last Name: Current Address:
Medical History Form Patient Information Salutation: Sex: Current Address: Email: Employer: First Name: Last Name: Middle Initial: Date: City: Zip Code: Phone 1: Phone 2: Date of Birth: Referral Source:
Logo Placement *######*
INPATIENT ADMITTING HISTORY AND PHYSICAL Page 1 of 8 Date of Service / / Time of Service : AM PM CHIEF COMPLAINT(S): HISTORY UNOBTAINABLE -- Patient was admitted UNACCOMPANIED, and no history could be
Assignments for SUM Program Beginning Medical Transcription, 2nd edition
Assignments for SUM Program Beginning, 2nd edition SECTION 1 Introduction, Dermatology/ Plastics Body () Unit 1, Body as a Whole, Ch. 1, Organization of the Body; Ch. 4, Tissues, Glands, etc., Ch. 5, Integumentary
A. Please include any medications (herbal, prescription, or Over-the-counter) and any supplements that you are currently taking.
New Patient Questionnaire Please complete this and bring it with you to your visit. If you have it completed five days or more prior to your visit, please mail or fax it to our office. Most recent treating
Name: Date: Street Address: Referring Physician: How long have you had your current problem?
3851 Piper Street, Suite U464 Anchorage, AK 99508 p 907.339.4800 f 907.339.4801 New Patient Health Questionnaire Name: Date: Street Address: City: State Zip Sex: Age: Birth Date: Insurance: SS# Home Phone:
DEMOGRAPHICS PHYSICAL ATTRIBUTES VITAL SIGNS. Protocol: ABC-123 SCREENING. Subject ID. Subject Initials. Visit Date: / / [ YYYY/MM/DD]
![DEMOGRAPHICS PHYSICAL ATTRIBUTES VITAL SIGNS. Protocol: ABC-123 SCREENING. Subject ID. Subject Initials. Visit Date: / / [ YYYY/MM/DD]](/thumbs/78/78699510.jpg "DEMOGRAPHICS PHYSICAL ATTRIBUTES VITAL SIGNS. Protocol: ABC-123 SCREENING. Subject ID. Subject Initials. Visit Date: / / [ YYYY/MM/DD]")
SCREENING Visit Date: DEMOGRAPHICS / / [YYYY/MM/DD] Consent Signed Date and time / / [YYYY/MM/DD] : Has written assent been obtained? If no, why not? YES NO Gender: Male Female Birthdate: Permission given
Name: Date: Referring Provider: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary).
Name: Date: Referring Provider: Age: D.O.B. Race/ ethnicity: What is the nature of your current gynecologic or urologic medical problem (use the other side if necessary). We are interested in learning
Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6
Center for Advanced Wound Care New Patient Questionnaire Page 1 of 6 These questions are general screening questions designed to identify areas where additional attention may be required. Please bring
Amarillo Surgical Group Doctor: Date:
Office Visit Information (General Surgery) Amarillo Surgical Group Doctor: Date: Patient s Information Name: Last First Middle Social Security #: Date of Birth: Age Gender: [ Male / Female ] Marital Status:
Effective Case Presentations
Effective Case Presentations Alan Lefor MD MPH Department of Surgery Jichi Medical University 4 4 Alan Lefor 1. History The complete medical history always should have six parts It begins with the Chief
PATIENT MEDICAL HISTORY
PATIENT MEDICAL HISTORY **All of the information requested is extremely important. We need complete and concise answers to** ALL of the questions in order to provide you with the safest and very best medical
Primary Chief Complaint 1. Location 2. When did this begin? 3. How did this begin?
Name Date These questions that you are about to answer are very important for the Doctor. They will enable the doctor make a complete and diagnosis, and provide medical documentation (if needed)to your
WELCOME TO COPPELL VISION CENTER 541 E. Sandy Lake Road, Coppell, Texas (972) Personal Information
WELCOME TO COPPELL VISION CENTER 541 E. Sandy Lake Road, Coppell, Texas 75019 (972) 393-3937 (Please Print Clearly) Personal Information Last Name: First Name: Exam Date: / / Street Address: City/State/Zip:
CECILIA P MARGRET MD PhD MPH Child, Adolescent and Adult Psychiatry NE 24th ST Suite 104, Bellevue WA 98007, Phone / Fax: +1 (425)
IDENTIFYING INFORMATION PATIENT INFORMATION FORM Patient's Name: DOB: Ethnicity/race: Gender: Primary language if other than English: Address: Phone: Home/ Mobile/ Work Email: Occupation: Marital Status:
Modesto Gastroenterology Medical Corporation
Page 1 of 5 Modesto Gastroenterology Medical Corporation Magdy S. Elsakr, M.D. Board Certified Gastroenterologist 2336 Sylvan Avenue, Suite A, Modesto, CA 95355, Phone: 209-338-0292, Fax: 209-338-0298
Fundamental E&M for Primary Care Risk Adjustment 2010
2-hr Fundamental E&M for Primary Care Risk Adjustment 2010 E/M Relevance to Diagnosis Coding Presented by: Liz Jeremia Market Consultant Toni Toone, CPC, CPMA Sr. Provider Training & Development Consultant
PATIENT INFORMATION. First
GUIDE DOGS OF AMERICA General Physician s Report This General Physician s Report is being requested in connection with an application for a guide dog. We require a recent physical exam and complete medical
The 1995 and 1997 AMA HCFA E/M Guidelines describes three levels of ROS:
The Most Common Cause of Down-Coded E & M Encounters The review of systems component must be adequately documented. By Ken Malkin, D.P.M. Dr. Malkin is a diplomate of the American Board of Quality Assurance
PATIENT REGISTRATION
P Account# PATIENT REGISTRATION Please answer all questions completely. PAYMENT IS EXPECTED WHEN SERVICES ARE RENDERED Date New Update Name Date of Birth Male Last First Middle Female Home Address City/State/Zip
Subject Ch Hours Date Preparatory Intro to Course 4 9/4. Safety and Wellness 2 2 9/11 Public Health 3 2. Medical, Legal and Ethical Issues 4 4 9/13
Subject Ch Hours Date Preparatory Intro to Course 4 9/4 Intro to Course (continued) 2 9/6 EMS Systems 1 2 Safety and Wellness 2 2 9/11 Public Health 3 2 Medical, Legal and Ethical Issues 4 4 9/13 Medical,
NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW- UP NEUROLOGY QUESTIONNAIRE
Neurology East 48 Medical Park Dr. East Richard G. Diethelm, MD Suite 351 Andrea Sutton, RN, MSN, ANP- BC Birmingham, AL 35235 (205) 836-9366 www.neurologyeast.com NEW PATIENT, UPDATE, OR HOSPITAL FOLLOW-
Patient Interview Form
Page 1 of 6 Patient Interview Form Patient Information First Name: MRN: Age: Last Name: Date Of Birth: Notes: Email Please check one as your preferred email for communications Personal: Work: Race Select
PEDIATRIC MEDICAL HISTORY QUESTIONNAIRE
Division of Otolaryngology Main Phone: 847 504-3300 Main Fax: 847 504-3305 Mihir Bhayani, MD Judy L. Chen, MD Mark E. Gerber, MD, FACS, FAAP Joseph Raviv, MD Ilana Seligman, MD, FACS, FAAP Michael J. Shinners,
NEW PATIENT HEALTH HISTORY
NEW PATIENT HEALTH HISTORY Patient Name Today s Date Age Birth Date Date of last physical examination What is your reason for initial visit? Pharmacy Name & Telephone # NOTE: If you have prior records
Patient Medical History Form Pre-Surgical Bleeding History Questionnaire Name:
Patient Medical History Form Pre-Surgical Bleeding History Questionnaire Name: CIRCLE the appropriate response: Y yes or N no. A. Patient History 1. Has the patient ever had surgery, stitches for trauma
New Patient Intake Form
New Patient Intake Form Title: (Check one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name _ Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
GASTROCARE, P.C. Contact Preference: HOME: Cell #: Office #: REASON FOR VISIT: Allergies: Current Medications (Name/Dose/How taken):
GASTROCARE, P.C. DR. A.B. REDDY, M.D., F.A.C.G. DR. REKHA KHURANA, M.D. Referring Physician: First Name: Date of Birth: Last name: Age: Pharmacy (include location): Fax Number: Email Address: Gender: Male
Welcome to the Kentucky Neuroscience Institute at the University of Kentucky!
Welcome to the Kentucky Neuroscience Institute at the University of Kentucky! The Kentucky Neuroscience Institute is on the first floor of the Kentucky Clinic. The address is 740 South Limestone Street,
Study Abroad Physical Exam, Consent, and Release Form (Page 1 of 8)
Study Abroad Physical Exam, Consent, and Release Form (Page 1 of 8) In submission of this form, I acknowledge that New York University has no obligation to seek any medical treatment whatsoever on my behalf.
Patient Last Name First Name Middle Name. Home Address City State Zip. Date of Birth Age Social Security # - - Cell Phone Home Phone Work Phone
Date Patient Last Name First Name Middle Name Gender (circle): Male Female Other: Marital Status (circle): Single Married Divorced Widowed Separated Home Address City State Zip Date of Birth Age Social
Premier Internal Medicine of Alpharetta, PC
Patient Information Date / / First Name Middle Initial Last Name Date of Birth / / Social Security # Gender Male Female Marital Status Single Married Separated Divorced Widowed Address Apt # City State
Please be sure to check with your insurance company to make sure that Dr. Kohli is covered under your plan.
Dear You are scheduled for an appointment with Dr. Manoj Kohli at Christie Clinic in the Department of Rheumatology on at. Please check in on the first floor. The office is located on the 2 nd floor of
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in.
Please have your health insurance card(s), a valid picture ID, and any applicable copayment ready when you check-in. We have enclosed a questionnaire for you to complete and bring to the visit. Please
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure
DNA CENTER New Patient Information
DNA CENTER New Patient Information Name Email: Address City State Zip Home Phone Work Cell Phone Social Security Number Date of birth Gender ( Male/Female) Age Please Circle: Hispanic/Latin or Non Hispanic/Latin
Evergreen Speech & Hearing Clinic, Inc. Transforming Lives Through Improved Communication Since 1979
Patient Information Form Patient Information Patient Name: Date of Birth: / / Age: Last First MI mo day year Gender: Email Address: Address: City: State: Zip Code: Cell Phone: Home Phone: Work Phone: Referred
History: Going the Distance. Suzan Berman, CPC, CEMC, CEDC
History: Going the Distance Suzan Berman, CPC, CEMC, CEDC Publisher Notice Although we have tried to include accurate and comprehensive information in this presentation, please remember it is not intended
IF YOU HAVE A MEDICAL LIST WITH YOU, PLEASE SUBMIT IT WITH THIS FORM.
Dr. Doug Scherr Date of Birth: Date: CHIEF COMPLAINT What is the main reason for your visit today? ALLERGIES Are you allergic to any of the following? Please check YES or NO for each. Check here if you
Southern Maine Integrative Health Center Adult Intake Form
Southern Maine Integrative Health Center Adult Intake Form Patient Name: Address: Birthdate: / / Age: / / City: State/Zip: Home Telephone: ( ) Work Telephone: ( ) Employer: Cell phone: ( ) Email Address:
Cy-Fair Hearing Aids Case History Form. Brandy R Jacobson Au.D. PERSONAL INFORMATION. Patient Name: Appointment Date: Date of Birth: Age: Gender: Male
Cy-Fair Hearing Aids Case History Form Brandy R Jacobson Au.D. PERSONAL INFORMATION Patient Name: Appointment Date: Date of Birth: Age: Gender: Male Female Marital Status: Single Married Divorced Widowed
Competencies and Objectives
Competencies and Objectives Chapter 1 EMS Systems Preparatory Emergency Medical Services (EMS) Systems Research Public Health Chapter 2 Workforce Safety and Wellness Medicine Infectious Diseases Preparatory
8/3/2011. Presented by: Brenda Edwards, CPC, CPMA, CPC I, CEMC AAPCCA Board of Directors. Documentation. Results ? 2
Presented by: Brenda Edwards, CPC, CPMA, CPC I, CEMC AAPCCA Board of Directors 1 Documentation Auditing Results? 2 1 HANDWRITTEN Legibility Personalized DICTATED Concise Personalized Timely? EMR Lengthy,
Patient Intake Form for Allegany Ear, Nose, & Throat
Patient Intake Form for Allegany Ear, se, & Throat Patient Name: What brings you to the office today? Who is your primary care doctor? Please list your current medications: Are you allergic to any medications?
Health History Form Please Fill Out Entire Form
Health History Form Please Fill Out Entire Form Name: Primary Physician: Referring Provider: Review of Symptoms: Check all that apply Date of Birth: Phone: Additional Concerns: Eyes: Blurry Vision Burning/Dryness
The Premier Vein Center Evan Oblonsky MD 1051 W. Rand Road, Suite 104 Arlington Heights, IL Tel: Fax:
PATIENT INFORMATION (PLEASE PRINT) Patient Name: Nickname: Guardian: Date of Birth: Sex: Address: 2nd Address: Home Phone: Work Phone: Cell Phone: Best Number: License / ID# Contact Email: Emergency Contact:
NEW PATIENT HISTORY FORM. Are you diabetic? YES NO Diabetic Physician:
NEW PATIENT HISTORY FORM NAME Personal Health History Are you diabetic? YES NO Diabetic Physician: What Type of Diabetes Do You Have? DATE How long have you had diabetes? Do You Have Hepatitis? YES NO
insurance information
patient information Last Name: First Name: MI: Date of Birth: / / (MM / DD / YYYY) Marital Status: single married other Sex: male female Home Address: City: State: Zip Code: Mailing Address (if different
SANTA MONICA BREAST CENTER INTAKE FORM
SANTA MONICA BREAST CENTER Who referred you to see us today? Who is your primary care physician? Are there any other MDs who you would like to receive today s visit information? No Yes MD contact info
Past Medical History. Chief Complaint: Appointment Date: Page 1
Appointment Page 1 Chief Complaint: (reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History EYES Yes No Yes Details Glaucoma EAR, NOSE AND THROAT Hearing difficulty
Patient Interview Form
Patient Interview Form Patient Information First Name: Last Name: Date of Birth: Age: Email Personal: Race Select one or more Referring Physician White Black or African Asian American Indian Native Hawaiian
Documentation- Overview. Coding for Emergency Department Services. Documentation Guidelines
Documentation- Overview Coding for Emergency Department Services Sarah Todt, RN, CPC, CPMA, CEDC Documentation Guidelines CMS 1995 CMS 1997 May choose guidelines that are most favorable to the provider
Medical History Form
Medical History Form Name: ; Birth date: / / ; Date: / / Person filling out form: ; Relationship: Thank you for taking the time to fill out this valuable information. This allows us to provide the best
CONSULTATION REFRESHER
060310 BLAST CONSULTATION REFRESHER We have had many requests from clients recently asking how to correctly code Medicare consultations utilizing the new CMS requirements. Attached is a mini refresher
PATIENT MEDICAL HISTORY
GEORGIA BRAIN AND SPINE CENTER 4355 Johns Creek Parkway Suite 520 Suwanee, GA 30024 Phone: (404) 446-4424 Fax: (404) 446-4420 www.georgiabrainandspine.com PATIENT MEDICAL HISTORY **All of the information
Hackensack(University(Medical(Group( (Urology( 360(Essex(Street,(Suite(403(((Ι(((Hackensack,(NJ(07601(((Ι(((551F996F8090((((Ι((((www.urologynj.
IHORS.SAWCZUK,M.D.,F.A.C.S. Professor & Chairman Chief, Urologic Oncology John Theurer Cancer Center Executive VP & Chief Medical Officer RAVIMUNVER,M.D.,F.A.C.S. Associate Professor & Vice Chairman Chief,
Patient Interview Form
Page 1 of 5 Patient Interview Form Patient Information First Name: MRN: Last Name: Date Of Birth: Contact Preference Email Telephone call- Work Telephone call - Home Email Please check one as your preferred
2016 Behavioral Medicine Resident Chart Documentation. Laura Sullivan, MSW, CPC Compliance Auditor
2016 Behavioral Medicine Resident Chart Documentation Laura Sullivan, MSW, CPC Compliance Auditor 1 Legal Stuff The information provided here is being provided by a nonlawyer and should not be construed
NEW PATIENT REGISTRATION PLEASE COMPLETE ALL ITEMS ON EACH PAGE. Name (Last, First, M.I.) Address. City State Zip Code. Phone ( ) Work ( ) Cell ( )
NEW PATIENT REGISTRATION PLEASE COMPLETE ALL ITEMS ON EACH PAGE Date Name (Last, First, M.I.) Address City State Zip Code Phone ( ) Work ( ) Cell ( ) Date of Birth Age Marital Status SSN Employer Employer
Sleep History Questionnaire
Sleep History Questionnaire Name: DOB: Phone: Date of Consultation: Consultation is requested by: Primary care provider: _ Preferred pharmacy: Chief complaint: Please tell us why you are here: How long
Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code:
Patient Information Last Name: First Name: Middle Initial: Address: City: State: Zip Code: Date of Birth (MM/DD/YY): Social Security #: Sex: Male Female Home Phone #: Mobile Phone #: Email Address: Marital
New Patient Sleep Intake
New Patient Sleep Intake Name: Date of Birth: Primary Care Physician: Date of Visit: Referring Physician and/or Other Physicians: Retail Pharmacy: Mail Order Pharmacy: Address: Mail Order Phone #: Phone
Pain Management Questionnaire
In order to make the most of your visit, we require this form to be completed to the best of your ability and sent to the Pain Management Clinic a copy should be shared with your Primary Care Provider
Medical History Form
Medical History Form NAME DOB / / TODAY S DATE MEDICAL HISTORY What medical Conditions do you have? Select all that apply, or write in if not listed: Diabetes High Blood Pressure Thyroid Disorder Heart
MISSOURI SPINE INSTITUTE John D. Spears, D.O.
MISSOURI SPINE INSTITUTE John D. Spears, D.O. : / / Patient Name: Office Use Only Right/Left Handed BP: / Pulse: Height: Weight: BMI: Primary Care Physician: Cardiologist: of Birth: / / Age: Sex: M F Please
Patient Information. Insurance Information
Thoracic Group, PA Hyperhidrosis Center at Thoracic Group PA Robert J. Caccavale, MD Jean-Philippe Bocage, MD (732) 247-3002 Patient Information Name: Date: Date of Birth: Social Security #: Street Address:
THE OB/GYN CENTRE NEW PATIENT HISTORY
PERSONAL PROFILE NAME: AGE: NAME YOU WOULD LIKE US TO USE: OCCUPATION: MARITAL STATUS: GYNECOLOGICAL HISTORY LAST MENSTRUAL PERIOD (FIRST DAY): AGE PERIOD BEGAN: PRESENT BIRTH CONTROL PAST METHODS OF BIRTH
Dear Incoming Student:
Dear Incoming Student: As the Director of Wellness Services, I want to welcome you to Nyack College! Our Staff is dedicated to providing you with quality health care. Our philosophy is based on the wellness
Medicare & Dual Options Annual Comprehensive Exam FAX COMPLETED FORM TO: Patient Personal Information
FAX COMPLETED FM TO: 877-682-2216 All fields marked with an * are required to be completed in order to receive payment for the ACE Form, unless indicated otherwise. Please refer to the document titled
WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS
WELCOME TO THE NORTHSHORE UNIVERSITY HEALTHSYSTEM SLEEP CENTERS Prior to your office visit, we request that you complete this questionnaire. It asks questions not only about your sleeping habits and behavior
New Patient Information. Which Physician will you be seeing today? How did you hear about our practice?
New Patient Information Which Physician will you be seeing today? How did you hear about our practice? Local Pharmacy Name: Pharmacy Phone #: Pharmacy Location/Address: Name Preferred Age: (Last) (First)
PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes.
Name: DOB: PERSONAL MEDICAL AND FAMILY HISTORY Please check applicable boxes. TOBACCO USE: Quit Date Cigarettes Packs/Day Number of years smoked Pipe/Cigar Smokeless Tobacco Electronic or E-cigarette Secondhand
Sleep Center. Have you had a previous sleep study? Yes No If so, when and where? Name of facility Address
Patient Label For office use only Appt date: Clinician: Sleep Center Main Campus Highlands Ranch Location 1400 Jackson Street 8671 S. Quebec St., Ste 120 Denver, CO 80206 Highlands Ranch, CO 80130 Leading
Date of Visit / / Date of Birth / / Age
New Patient Health Questionnaire Date of Visit / / Date of Birth / / Age Email Race: Non-Hispanic Hispanic Preferred Language: English Other Do you have advanced directives: living will, power of attorney
Past Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma
Student Full Name: Date of Birth:
Student Medical Form This form is to be completed for new students upon admission, and returning students prior to starting grades 3, 6, and 9. Students participating in athletics must complete form every
H&P Checklist (Inpatient) Evaluator: Subject: Program:
H&P Checklist (Inpatient) Evaluator: Subject: Program: PROFESSIONALISM 1) Introduces self/role and preceptor Did 2) Verbal and non-verbal language demonstrates respect for patient & family. Did 3) Respects
Dr. Cheng s NECK & BACK QUESTIONNAIRE FOR NEW PATIENT (Please complete this form and bring it with you on your visit)
Dr. Cheng s NECK & BACK QUESTIONNAIRE FOR NEW PATIENT (Please complete this form and bring it with you on your visit) Last name: First Name: Title: Mr. Mrs. Dr. Appt Date: Refer by: (Please provide name
725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA (770) (770) (facsimile)
Charles Nash, III, M.D., F.A.C.P. Richard J. LoCicero, M.D. Anup K. Lahiry, M.D. Timothy M. Carey, M.D. Andrew Johnson, M.D. 725 Jesse Jewell Pkwy, Suite 390 Gainesville, GA 30501 (770) 297-5700 (770)
NEW PATIENT APPOINTMENT UROLOGY
Urology 2119 East South Blvd. 2 nd Floor Phone: 334-613-7070 NEW PATIENT APPOINTMENT UROLOGY, you have an appointment with Dr. Geoffrey Habermacher Dr. Joseph Pazona Larry Thomas CRNP Sherry Henning CRNP
Hospital he hospital is located near the interchange of highway 217 and (US 26).
Welcome to our Clinic! Our goal is to provide you with the highest quality medical care available. Please bring the completed enclosed paperwork along with your insurance card and legal picture ID to your
Scottsdale Family Health
Please list pharmacy you would like us to use for your medications. Pharmacy Phone Number Fax Number Since your last visit: 1. Have you been diagnosed with any new medical conditions? Yes No If Yes (give
Effective January 1, 2003
Effective January 1, 2003 Because children are more susceptible to communicable diseases and illnesses it is important that staff and parents follow strict control practices. As a result we have created
Welcome to the Centre for Aging and Wellness at Florida Hospital!
133 Benmore Dr. Winter Park, FL 32789 PH: 407-599-6060 FAX: 407-646-7747 Welcome to the Centre for Aging and Wellness at Florida Hospital! We are pleased you have chosen us as part of your health care
MCKAY UROLOGY LINCOLNTON OFFICE PATIENT HISTORY FORM
Patient name: MRN #: Current Medications (prescription and over the counter medications including vitamins, herbs, aspirin, antacids, injectables, hormones and birth control medication) If you brought
Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, Ph: , Fax:
Columbus Oncology and Hematology Associates 810 Jasonway Ave. Columbus, OH 43214, www.coainc.cc Ph: 614.442.3130, Fax: 614.442.3145 Name (Last, First, Middle) Birth Date Age Social Security # Appointment
PATIENT HISTORY FORM
Please bring completed history form to your scheduled appointment, if not completed this could delay your office visit. Thank you PATIENT HISTORY FORM Appointment Date Appointment Time Name Referring Physician
Evaluation & Mangement ( E & M) Visits Adapted from 1997 CMS Guidance Using Single Organ System
5/7/15 University of Rochester Center for Health & Behavioral Training 1 Evaluation & Mangement ( E & M) Visits Adapted from 1997 CMS Guidance Using Single Organ System New Patient Office Visit [Patient
NEW PATIENT VISIT QUESTIONNAIRE
HeartHealth A Program of the Dalio Institute of Cardiovascular Imaging NEW PATIENT VISIT QUESTIONNAIRE Name: Date of Birth: / / Address: City: State: Zip: Home Phone #: Work Phone #: Cell #: Email: Preferred