Transcription of er emb mm/dd/yyyy - eviCore
{{id}} {{{paragraph}}}
Example: stock market
er emb mm/dd/yyyy - eviCore
First Name:Middle I nitial:Last Name:DOB ( mm/dd/yyyy ):Gender:MaleFemaleStreet Address:Apt #:City:State:Zip:Cell P hone:Primary Contact:HomeCellHealth Plan:Member ID:Group I D:First Name:Last Name:Primary S pecialty:TIN:NPI:Physician P hone:Physician Fax:Address:Suite #:City:State:Zip:Office Contact:Ext:Contact Email:First Name:Last Name:Group/Site Name:Primary S pecialty:TIN:NPI:Site Phone:Site Fax:Address:Suite #:City:State:Zip:Diagnosis, i f k nown or r ule out:ICD-10 Codes:PTOTR eference/Auth Number ( if c ontinued c are):Date of l ast v isit:Start date of th is r equest:Page 1 of 3PT/OT Treatment Request Clinical Worksheet Neurologic ConditionsDiagnosisCONFIDENTIALITY NOTICE: This fax transmission, and any documents attached to it may contain confidential or privileged information subject to privacyregulations such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Reduced strength full range Can't move against gravity Hand function. Reduced strength full range Fingertips don't reach palm Normal strength Normal strength Raises with bent knee Unable
Tags:
Information
Domain:
Source:
Link to this page:
Please notify us if you found a problem with this document: