Medicare Health Risk Assessment Questionnaire
|
|
|
- Jack Johnson
- 5 years ago
- Views:
Transcription
1 Medicare Health Risk Assessment Questionnaire Instructions: Please complete and return it in the self-addressed stamped envelope provided. If you have questions or need help completing the questionnaire, call our toll free line at Monday- Friday 9am 5 pm. ONECare uses this questionnaire to assist in assessing your health status. Your Name: Street Address: City, Zip Code: Day Phone: ONECare ID#: Please check the appropriate box that answers the questions below and write any additional pertinent information that will help us meet your needs better. 1. Did you receive your ONECare new member packet and ID Card? 2. What is your primary language? 3. Survey completed by: Member Other (Please explain) 4. Do you have any cultural, spiritual or language needs that make it difficult to follow your medical treatment plan? If yes, please explain. 5. What is the name of your Primary Care Physician (PCP)? 6. When was the last time you saw your PCP? 7. Do you see any specialty doctors? 8. If yes, please list specialty or specialties? 9. Do you get a flu shot every year? When and where did you get it last? 10. Have you ever had a pneumonia shot? If yes, when? 11. Have you ever had a colonoscopy? 12. If you have had a colonoscopy, date of service?
2 13. Where did you have the colonoscopy? 14. Females- have you had a pelvic exam and a PAP smear test in the last year? 15. What was the date of your most recent PAP smear? 16. Have you had an abnormal PAP smear? 17. When was your last mammogram? Date 18. For Males: Have you had a Prostate exam? 19. What was the date of your last Prostate exam? 20. Have you been to an emergency room in the last 6 months? 21. If yes, how many times? 22. Why did you go to the emergency room? 23. Have you stayed overnight in a hospital in the past 6 months? 24. If yes, how many times? 25. If yes, give reason(s)? 26. Have you been in a skilled nursing facility in the past 6 months? 27. If yes, which facility? 28. If yes, give reason? 29. Prescription medication you are currently taking?
3 **If more, please include a separate sheet with information** 30. Over-the-counter products (vitamins, supplements, herbal, other) you are currently taking? Name of product: Name of product: Name of product:
4 _ 31. Names of any alternative treatment you are taking, prescription or non-prescription. 32. Do you use any special equipment because of a disability or health problem such as walker or a cane? Please list _ 33. Do you use any medical supplies at home such as diabetic supplies or dressing supplies? Please list. 34. Are you currently receiving any services from an agency such as home health or Meals on Wheels? Please list. 35. Are you currently being treated for any health conditions such as breathing or heart problems? What health problems are you being treated for? 36. Do you have Diabetes? If Yes, 37. Do you check your blood sugars? 38. Have you had a vision exam within the last year? 39. If yes, what was the date of service? For Non-Diabetic Members: 40. Have you had a vision exam within the last year? 41. Are you currently experiencing any vision problems? Please explain 42. Have you had a Glaucoma Eye Screen in the last 12 months? 43. Do you wear glasses or contact lenses?
5 44. Do you need any adaptive equipment, testing, treatment or assistance with your vision? 45. If yes, what type of assistance is needed (provider referral, glasses/contact lenses, other adaptive equipment or assistance). 46. Would you like information on your vision benefits? 47. Do you have or have you been treated for asthma? 48. Do you use an Inhaler? 49. Many of us have had pain from time to time (such as minor headaches, sprains, toothaches). Do you have pain other than these everyday kinds of pain? 50. If yes, where do you have pain? 51. Do you have pain that requires pain medicine every day? 52. When did you last take pain medicine? What did you take? 53. On a scale of 1-5, describe your overall pain level: (1 = NO Pain and 5 = severe) 54. How much does pain interfere with your day to day activities on a scale from 1 5? (1= no interference, 5 = interferes greatly) Please describe: 55. In the past three months, has it been harder for you to speak, think or remember things? Yes No If yes, please explain 56. Do you live alone? If no, with whom do you live? 57. Do you feel you need help getting the care you need? 58. Are you able to perform your activities of daily living such as bathing and dressing? Which activities of daily living do you need help to be able to complete?
6 59. If you receive help with any of the activities in the above question, who is the helper? Name: Relationship: Phone number: 60. May we contact your helper/caregiver? 61. Have you fallen in the past 6 months? 62. If yes, how many times? 63. Do you have any open wounds or bed sores? 64. Are you enrolled in a behavioral health program? If yes, which one? 65. What condition(s) are you being treated for? 66. Are you depressed or ever thought about hurting yourself? 67. Are you having a problem with Alcohol or Drugs? 68. Do you drink alcohol (beer, wine, hard liquor)? # beers per day # wine per day # hard liquor per day 69. Do you smoke? If yes, how much do you smoke? 70. Would you like information on quitting smoking? 71. Have you completed an Advanced Directive? (a document that directs your health care wishes in the event you become unable to make them or designates someone to make them on your behalf). 72. If yes, is it on file with your PCP? 73. If no, are you interested in receiving information about advanced directives?
7 74. Are you currently experiencing any hearing problems? 75. If yes, please explain: 76. Have you had a hearing exam? 77. Do you wear hearing aids? 78. Do you need any adaptive equipment, testing, treatment or assistance with your hearing? 79. If yes, type of assistance needed: (e.g. referral to provider, hearing aids, other adaptive equipment or assistance) 80. Would you like information on your hearing benefits? 81. Is there anything else you would like us to know about you? I understand that this information may be shared with my physician. Signature Today s Date Thank you for your time in completing this questionnaire
Medicare Annual Wellness Visit Questionnaire 1} 3} 5} 2} 4} 6} 1} 3) 5) 2) 4) 6) 1} 4) 2} 5) Date: Name: LAST FIRST MIDDLE
CLIENT HEALTH QUESTIONNAIRE AND INITIAL SCREENING QUESTIONS HEALTH QUESTIONNAIRE INSTRUCTIONS
CLIENT HEALTH QUESTIONNAIRE AND INITIAL SCREENING QUESTIONS HEALTH QUESTIONNAIRE INSTRUCTIONS If Incidental Medical Services (IMS) are to be provided, the Incidental Medical Services Certification Form
New Student-Athlete Checklist
New Student-Athlete Checklist Pre-Participation Physical (must use form attached) Complete Athletic Training Forms online (see attached instructions) BESS/SCAT/ImPact Test (when arrive) Should you have
Application for Residential Services
Check for which program applying for: Macleigh/VA Beach Kilmarnock/Rappahanock Colonial Beach/Colonial Beach Lynchburg Garber Morris/Varina Bonnie/Stuarts Draft Saratoga/Winchester Tate/Ashland Mary Beth
Olympia Family Medicine 5949 Harbour Park Drive Midlothian, VA 23112
Olympia Family Medicine 5949 Harbour Park Drive Midlothian, VA 23112 Patient Registration Date Name DOB Age SSN Sex: M F Address City State Zip Code Home Phone # Cell Phone # Work Phone Occupation Employer
HEALTH HISTORY QUESTIONNAIRE
L 3/11 Page 1 HEALTH HISTORY QUESTIONNAIRE NAME: DATE: HOME ADDRESS: HOME PHONE: WORK PHONE: CELL PHONE: OTHER PHONE: EMPLOYER: OCCUPATION: EXPLAIN YOUR JOB DUTIES: DATE OF BIRTH: SEX: MALE /FEMALE SS#
EYECARE REGISTRATION AND HISTORY
EYECARE REGISTRATION AND HISTORY PATIENT INFORMATION INSURANCE Date Who is responsible for this account? Patient Relationship to Patient Address Insurance Co. Group # City State Zip Is patient covered
PATIENT INFORMATION SPOUSE INFORMATION REFERRAL INFORMATION INSURANCE INFORMATION IN CASE OF EMERGENCY
Today s date: PATIENT INFORMATION Patient s Last name: First: Middle: Physician Name: Mr. Sex: Marital status (circle one) Single / Mar / Div / Sep / Wid Mailing address: City: State: ZIP Code: D.O.B:
New Student-Athlete Checklist
New Student-Athlete Checklist Pre-Participation Physical (must use form attached) Verify Primary Insurance(see attached instructions) Complete Athletic Training Forms online (see attached instructions)
Vine Medical Group Patient Registration Form Your Information
Your Information Welcome to Vine Medical Group. In order for us to offer you the high standards of clinical care we give to our patients, we ask that you complete this registration form. Before we are
What is New in MyChart? My Medical Record Health Preferences Settings Appointments and Visits Visits Schedule an Appointment Update Information
What is New in MyChart? On August 26th, we will be upgrading and changing the look and feel to our MyChart patient portal site. We would like to make you aware of a few differences that you will see, when
Lifeway Child/Adolescent Information Form
Date / / Lifeway Child/Adolescent Information Form Patient Name: First MI Last Date of Birth: / / Gender: M F Marital Status: M S D Address: City State: Zip: Primary Contact Phone: Secondary Contact Phone:
NEW PATIENT HISTORY FORM. Name: Main Reasons for coming to the office: Duration of Problem (when did it first start?):
NEW PATIENT HISTORY FORM Main Reasons for coming to the office: Location of Problem(s): Please briefly describe the problem(s): How severe is your problem (please circle): Duration of Problem (when did
Personal Information. New Profile Icon
What is New in MyChart? On December 8th, we will be upgrading our MyChart patient portal site. We would like to make you aware of a few differences that you will see, when you sign into your MyChart account.
My Care Plus Your reference guide. MyCarePlusOnline.com
My Care Plus Your reference guide. MyCarePlusOnline.com Your personal and health information is protected and secure on My Care Plus, as directed by our privacy policy. 2 Table of Contents 1) My Care Plus...
Family doctor services registration
GMS1-JUL12_GMS 1 17/07/2012 13:15 Page 1 Family doctor services registration GMS1 Patient s details n Mr n Mrs n Miss n Ms Date of birth Surname First names Please complete in BLOCK CAPITALS and tick n
GUADALUPE ENT, P.A. JENNIFER G. HENNESSEE, M.D. MAANSI DOSHI, D.O. LISA M. WRIGHT, PA
GUADALUPE ENT, P.A. JENNIFER G. HENNESSEE, M.D. MAANSI DOSHI, D.O. LISA M. WRIGHT, PA Patient Profile Last Name First Name Middle Name of Birth Gender Social Security Number Marital Status Email Race Ethnic
Intake Application Please complete all sections of this application and do not leave any blanks. Please print.
Return to CP Rochester 1000 Elmwood Ave. Suite 900 Rochester, NY 14620 585-295-1587 ext. 2281 Intake Application Please complete all sections of this application and do not leave any blanks. Please print.
Please do not leave anything blank. If something does not apply please put N/A.
Name: _ Date of Birth Date Please describe the reason for your visit. Include Symptoms, duration, location, and severity: Select any of the following medical conditions that you currently have: Anxiety
Adult History Form. Personal Information. Name: Birthdate: Age: Social Security number: Street Address: Cell:
Date: Adult History Form Please complete this detailed history form and return it to the front desk. If you have any questions or need assistance with anything, please let us know. Personal Information
CLIENT APPLICATION FORM
CLIENT APPLICATION FORM ACCESS-A-Ride Lethbridge Transit 619 4 th Avenue North Lethbridge, AB T1H 0K4 Phone 403-329-6464 Fax 403-380-3876 AAR@lethbridge.ca ACCESS-A-Ride is a specialized Lethbridge Transit
JON PEMBROKE KELLY, M.D., F.A.A.O.S. ORTHOPAEDIC SURGERY PATIENT QUESTIONNAIRE
JON PEMBROKE KELLY, M.D., F.A.A.O.S. ORTHOPAEDIC SURGERY PATIENT QUESTIONNAIRE Date of Examination Office Location Name DOB Age Soc. Sec. # Address City Telephone Number ( State Zip ) Height ft. in. Right-handed
New Beginnings Long-Term Treatment Program
New Beginnings Long-Term Treatment Program To be eligible for the New Beginnings Program, you must: A. Be a resident of Kalamazoo County. B. Be a male with a history of alcohol or drug abuse. C. Be homeless
Lifeway Adult Information Form
Date / / Patient Name: First Lifeway Adult Information Form MI Last Date of Birth: / / Gender: M F Marital Status: M S D Address: City State: Zip: Primary Contact Phone: Secondary Contact Phone: Please
DONE! You can now close the browser.
Visit My Doctor Online at kp.org/mydoctor. Prepare for your visit This form will help you prepare for your upcoming visit with your doctor. You can complete it on your computer (Mac or PC) and e-mail it
The Chest Wall Center at Cincinnati Children s Patient Questionnaire
Today s Date Patient Name First Middle Last Date of Birth Age Home Phone Cell Work Email(s) Address(es) Primary Care Doctor (PCP) PCP S Address Street Address City State Zip PCP S Phone Number Which surgeon
LIFEWAY PREMARITAL INFORMATION FORM LIFEWAY REFERRAL INFORMATION
LIFEWAY PREMARITAL INFORMATION FORM Date: / / Name: First MI Last Date of Birth: / / Gender: M F Marital Status: Single Engaged Divorced Address: City State: Zip: Primary Contact Phone: Secondary Contact
Questionnaire 3. (only to be filled out when submitting blood and stool sample) This box will be filled out by the practice team
Questionnaire 3 (only to be filled out when submitting blood and stool sample) Date This box will be filled out by the practice team Patient-ID Barcode on labels Dear participant, We are pleased that you
Hematology Oncology Associate of Central New York Medical History
Hematology Oncology Associate of Central New York Medical History Name: Date: Male Female Age: Consult Date: Reason for today s visit: Referring Doctor: Primary Care Doctor: Surgeon & Other Doctors: Medical
Admission Application: Intensive Residential Rehabilitation / Community Residence / Supportive Living COVER PAGE
COVER PAGE Please check which level of care to which the applicant is applying. Complete referral packages* should be faxed to (716) 362-0221 or scanned and emailed to intake@cazenoviarecovery.org. Thank
Lasting Power of Attorney for Health and Welfare A guide to filling in the form
Information Line: 0800 999 2434 Website: compassionindying.org.uk Lasting Power of Attorney for Health and Welfare A guide to filling in the form This factsheet aims to support you to fill in the form
ADULT VOLUNTEER SERVICES APPLICATION
ADULT VOLUNTEER SERVICES APPLICATION Adult - For Internal Use: Certifications: Community Service: PERSONAL INFORMATION First Middle Last Date of Birth Social Security # Driver s License # Photo Copy [
CLINTON COUNSELING CENTER STUDENT SOCIAL MEDICAL QUESTIONNAIRE
CLINTON COUNSELING CENTER STUDENT SOCIAL MEDICAL QUESTIONNAIRE Please respond to ALL questions/information. There are multiple two sided pages. Check to be sure you have completed them all. Provide the
NEW LIFE FOR YOUTH ENROLLMENT APPLICATION
FACILITY 2 FACILITY 1 NEW LIFE FOR YOUTH ENROLLMENT APPLICATION GENERAL INFORMATION FIRST NAME LAST NAME MIDDLE CURRENT EMAIL PHONE GENDER (Circle) M F DATE OF BIRTH ARE YOU A U.S. CITIZEN? Y N IF YES,
Living Donor Kidney Program - Multi-Organ Transplant
Living Donor Kidney Program - Multi-Organ Transplant Toronto General Hospital, University Health Network 585 University Avenue Peter Munk Building 12 th Floor Room 100 G Toronto, ON M5G 2N2 Tel: 416-340-4800,
NHS website Profile editor user guide
NHS website Published 10 August 2018 Copyright 2018 NHS Digital Contents Introduction 3 What is the profile editor? 3 What s in a profile? 3 Viewing your profile 4 Managing your profile 5 Requesting editing
SoonerCare Provider Information
ATTACHMENT B-2006 SoonerCare Provider Program Information PLEASE READ THE DIRECTIONS CAREFULLY All providers must complete the Uniform Credentialing Application. It must be 100% complete, including required
ELBOW - New Patient Intake Form
Place label here Kristofer J. Jones, M.D. ELBOW - New Patient Intake Form Name Date Occupation _ Age DOB 1) Were you referred to this office? No Yes, Name 2) Who is your Internist or Primary Care Physician?
MyChart User Guide. RiverBend Medical group
MyChart User Guide RiverBend Medical group TABLE OF CONTENTS Accessing MyChart... 2 Password and Username Reset... 3 Activating Your MyChart Account... 6 MyChart Basics... 7 Current Health Issues... 8
PATIENT PORTAL ACCESS
PATIENT PORTAL ACCESS Thank you for choosing Clarinda Regional Health Center as your medical services provider. The mission at CRHC is to provide exceptional, individualized healthcare to each patient
myhealth myrewards Scheduling a biometric screening Health Provider Screening Your step-by-step instructions What is a biometric screening?
myhealth myrewards Scheduling a biometric screening What is a biometric screening? A biometric screening can help detect abnormal health values that may indicate significant risk of or presence of chronic
CareAffiliate Tips. Pharmacy. Authorizations Create and manage authorization requests for: *medical drugs
Pharmacy Authorizations Create and manage authorization requests for: *medical drugs 1 Important! Training There are several helpful tools to assist you in learning CareAffiliate. Log in at hap.org and
Signing up for My Lahey Chart
Signing up for My Lahey Chart What is My Lahey Chart? My Lahey Chart is a helpful service that allows you to connect with your doctor and your health information online, anytime. Using your personal computer
Welfare Power of Attorney Scotland
Information Line: 0800 999 2434 Website: compassionindying.org.uk Welfare Power of Attorney Scotland This factsheet explains what a Welfare Power of Attorney is and how to make one. It is for people living
C4Yourself External User Guide. External Page User Guide
External Page User Guide C-IV Page 1 2/29/2012 PURPOSE The purpose of this guide is to provide users with step-by-step instructions on completing an online Application and submitting the application through
SCRIPT: MA Enrollment Long Form
SCRIPT: MA Enrollment Long Form (Purpose: This script is to be used for Medicare Advantage plan telephone enrollment for new enrollments only. Telephone enrollment may be offered: 1. If the telephone call
This study is brought to you courtesy of.
This study is brought to you courtesy of www.google.com/think/insights Health Consumer Study The Role of Digital in Patients Healthcare Actions & Decisions Google/OTX U.S., December 2009 Background Demonstrate
Vision Services Application Overview
The Georgia Lions Lighthouse is a 501(c)3 nonprofit. Our mission is to provide vision and hearing services through education, detection, prevention, and treatment. The services we provide are made possible
Pain Relief USER GUIDE. Includes important safety information. Read all instructions before using device.
Pain Relief USER GUIDE Includes important safety information. Read all instructions before using device. The revive Light Therapy Pain Relief is intended for the relaxation of muscles and relief of muscle
HISTORY OF THE INJURY:
Patient Information: Name: Age: _ Date: _ Address: (complete mailing address) _ Phone No.: (_) FAX:_ EMAIL: Date Of Birth: _ Soc. Sec. No.: Male Female * Right Handed Left Handed Both * Height: _ Weight:
Automated Information System AIS telephone user guide
Automated Information System AIS telephone user guide May 2007 Department of Human Services Division of Medical Assistance Programs 500 Summer St NE, E 44 Salem, OR 97301-1077 1-800-527-5772 Contents I.
Tablet eenrollment User Guide
Tablet eenrollment User Guide Oct. 2013 Table of Contents Introduction... 2 What is the Tablet eenrollment Application?... 2 Compatibility Check... 2 Commissions Requirements... 2 Enrollment Essentials...
CONTACT INFORMATION. NAME: Last First Middle Initial. HOME ADDRESS (Please do not use P.O. boxes or P.O. ZIP codes as destination of correspondence):
CONTACT INFORMATION NAME: Last First Middle Initial Gender: Male Female Date of Birth: HOME ADDRESS (Please do not use P.O. boxes or P.O. ZIP codes as destination of correspondence): Address City State
LIFEWAY PREMARITAL INFORMATION FORM LIFEWAY REFERRAL INFORMATION
LIFEWAY PREMARITAL INFORMATION FORM Name: First MI Last Date of Birth: / / Gender: M F Marital Status: Single Engaged Divorced Address: City State: Zip: Primary Contact Phone: Secondary Contact Phone:
eschoolplus+ Medical Training Guide
eschoolplus+ Medical Training Guide Version 3.1 August 2016 Arkansas Public School Computer Network This page intentionally left blank Page 2 of 101 Table of Contents Student Medical Records Overview...
Guidelines for Completing the Residential Claim Form
Guidelines for Completing the Residential Claim Form 1. Bill only residential services (Room and Board, Care and Supervision, and Bed Holds) on the Residential Claim Form. All other services (including
HealthInfoNet CLINICAL PORTAL USER REFERENCE GUIDE. Revised: Page 1 of 24
HealthInfoNet CLINICAL PORTAL USER REFERENCE GUIDE Revised: 6.3.2015 Page 1 of 24 HealthInfoNet User Reference Guide INSIDE: Accessing HealthInfoNet (HIN) 3-5 Clinical Portal 6-11 Notifications and Worklists
Customer Service. For clinical issues: For device issues: In case of a medical emergency KAISER PERMANENTE WILL PROVIDE INSTRUCTIONS
User Guide Customer Service In case of a medical emergency Dial 9-1-1 or go to the nearest hospital. For clinical issues: KAISER PERMANENTE WILL PROVIDE INSTRUCTIONS Physical issues or symptoms (non-emergency)
St Gregory the Great Catholic School
St Gregory the Great Catholic School Absence from Exams You must attend all the exams for which you have been entered on your Candidate timetable. Misreading the timetable will NOT be accepted as a satisfactory
The Recovery and Monitoring Program of New Jersey (Keep this sheet for your files)
Welsh Commons, 1364 Welsh Road, Suite C-2, North Wales, PA 19454-1913, USA 800-732-DRUG (3784) Fax: 215371-1126 Internet: http://www.firstlab.com E-mail: mail@firstlab.com The Recovery and Monitoring Program
This template is provided by PSNC and NHS Employers, who have developed it to assist PCTs and pharmacy contractors.
Community Pharmacy Patient Questionnaire Worksheet This template is provided by PSNC and NHS Employers, who have developed it to assist PCTs and pharmacy contractors. Pharmacy contractors using this template
Samantha Bray Public Safety Education Campus Room 1911
Welcome to Clinical Site Requirements for Emergency Medical Technician Initial Samantha Bray scbray@waketech.edu 919-866-6122 Public Safety Education Campus Room 1911 Ordering Package Once you are cleared
Departmental Reports: Posted 48 Hours After the Report Reaches a Signed Status
What is My Noyes HEALTH? My Noyes Health offers patients personalized and secure online access to portions of your Noyes HEALTH record. My Noyes HEALTH enables you to securely use the Internet to help
Two hours - online EXAM PAPER MUST NOT BE REMOVED FROM THE EXAM ROOM UNIVERSITY OF MANCHESTER SCHOOL OF COMPUTER SCIENCE
COMP 60411 Two hours - online The exam will be taken on line. This paper version is made available as a backup In this event, only MCQ answers written in the boxes on the exam paper will be marked. EXAM
Patient Portal User Guide The Patient s Guide to Using the Portal
2014 Patient Portal User Guide The Patient s Guide to Using the Portal Table of Contents: What is the Patient Portal?...3 Enrolling in the Patient Portal.......... 4-19 A. Enrollment Option #1: First-Time
Aetna International Overview For The Church of Jesus Christ of Latter-day Saints
Aetna International Overview For The Church of Jesus Christ of Latter-day Saints Central America Missions Welcome to Aetna International! Aetna has partnered with Global Medical Management Inc. (GMMI),
CERECONS. Provider Training
CERECONS Provider Training February 2012 Table of Contents 1. Physician Dashboard 2 Eligibility Highlights 2 Clinical Alerts 3 Referral Alerts and Stats 4 Group Information 5 2. Edit Profile 6 3. Eligibility
User Guide v2.3. Finish reading by Thu, Mar 16
User Guide v2.3 Finish reading by Thu, Mar 16 Contents Contacts Introducing Samsung HeartWise Getting to know your Samsung Gear S3 watch Charging your watch Checking your watch network connection Authenticating
Contents. Customer Service. Introducing Samsung HeartWise. Getting to know your Samsung Gear S3 watch. Charging your watch
User Guide Contents Customer Service Introducing Samsung HeartWise Getting to know your Samsung Gear S3 watch Charging your watch Checking your watch network connection Authenticating your watch Measuring
Reciprocity Program Package
Reciprocity Program Package The following documents are included in this package. Please scroll down to view documents or click on the BLUE link. TABLE OF CONTENTS Reciprocity Program Information Reciprocity
2018 Purple Army Band Camp Form Checklist
2018 Purple Army Band Camp Form Checklist This year Jackson Local Schools is moving to online medical forms. Once your form is filled out for band, you will not need to fill it out again for other activities!
Revision History. Document Version. Date Name Comments /26/2017 Training and Development Initial Creation
Pharmaceutical Assistance Contract for the Elderly (PACE)/ Pharmaceutical Assistance Contract for the Elderly Needs Enhancement Tier (PACENET)Web Provider Enrollment/Provider Management Corporate User
Joining SportsWareOnLine
Dear New Jefferson College Athlete: Prior to participating on an athletic team for Jefferson College, athletes must provide your current address, emergency contacts, insurance, medical alert and health
(26) Disposition Program Referred to **Must complete 26 if 24 is: SCMH Adult Clinic, SCMH Youth Clinic, Adult Contractor or Youth Contractor
(1) Date Service Requested (2) Call Time a.m. p.m. (3) Caller Phone Number (4) Data Entered By (5) Method or Source of Referral (6) Client Preferred Language (7a) Program Completing Form (7b) Program RU
RETURNING STUDENT-ATHLETE
RETURNING STUDENT-ATHLETE MEDICAL ELIGIBILITY TUTORIAL Los Angeles Valley College Sports Medicine 2018-2019 SportsWare Online Prior to participating on a team at LA Valley College, athletes must provide
MDVIP Connect Portal User Manual
MDVIP Connect Portal User Manual For support, call MDVIP toll-free at 866-602-4081, Monday - Friday between 9am - 10pm ET or email support@mdvip.com. TABLE OF CONTENTS Contents Welcome...................................
Ask your doctor about getting a prescription for 90-days.
CVS/caremark Mail Service Pharmacy Program User Guide Healthy Advantage Plus HMO Getting started is easy! If you need your prescription filled right away, ask your doctor to write two prescriptions for
A PPLICATION C ENTRE FOR THE G REEK L ANGUAGE C ERTIFICATE OF A TTAINMENT IN G REEK. for participation in the examination.
MINISTRY OF EDUCATION, RESEARCH AND RELIGIOUS AFFAIRS C ENTRE FOR THE G REEK L ANGUAGE C ERTIFICATE OF A TTAINMENT IN G REEK A PPLICATION for participation in the examination of May 2017 1 T ERMS AND C
Nicola McFadzean Ducharme, N.D. Emily Poccia, N.D.
Nicola McFadzean Ducharme, N.D. Emily Poccia, N.D. Dear New Patient: Thank you for choosing RestorMedicine as your healthcare provider. We are dedicated to making your experience a most satisfying one.
Tips on Filling Out the Lifeline Care Plan Agreement Form
Tips on Filling Out the Lifeline Care Plan Agreement Form The following information is required for the processing of your Lifeline Application: Household Phone # - Include area code and phone number.
AUTHORIZATION TO RELEASE HEALTH INFORMATION
Request Completed Health Information Management AUTHORIZATION TO RELEASE HEALTH INFORMATION Completion of this form authorizes the use and/or disclosure (release) of individually identifiable health information,
QUICK START USER S GUIDE
QUICK START USER S GUIDE The Mount Nittany Health team is excited to bring you My Mount Nittany Health, the online tool that allows you to play a bigger part in your own healthcare journey. This Quick
LibreHealth Electronic Health Record
1 of 10 LibreHealth Electronic Health Record The LibreHealth EHR log in page can be accessed using Google Chrome and other common browsers. LibreHealth EHR is an open source EHR which means the programming
(10/17) PATIENT GUIDE
(10/17) PATIENT GUIDE Welcome to Parkview MyChart! mychart.parkview.com Welcome to your one story of care. As a patient of Parkview, you now have access to your health information from the convenience
NHPNet User Guide Updated August 2017
NHPNet User Guide Updated August 2017 Table of Contents Introduction... 3 How to Register for NHPNet... 6 Your Profile... 16 User Administration... 22 Authorizations & Referrals... 33 Provider Enrollment
Welcome to MyChart. Your Home Page... 2 Messaging Visits... 4
Welcome to MyChart This guide will give you an overview of MyChart s many features and how to use them. Click a topic below to learn more. Your Home Page... 2 Messaging... 2 View messages from or send
Status of Young Women & Girls in Illinois: Health
Health 1 Status of Young Women & Girls in Illinois: Health Prepared by Center for Urban Research and Learning Loyola University Chicago * * This research was completed by the Loyola University Chicago
2006 Community Connection and MO Go Local Statistics Report date: 04/15/06
2006 Community Connection and MO Go Local Statistics Statistic Apr May Jun (visits) 19,042 27,675 32,730 Community Connection unique visitors 8,489 14,054 18,920 Page views from MedlinePlus (visits) 1,194
Your mymeritain Personalized Member Website
Your mymeritain Personalized Member Website 2008 Meritain Health, Inc. Last Updated 5.23.2008 Your mymeritain Member Website The mymeritain Member Website offers Members a user-friendly web experience,
P A T I E N T C E N T E R E D M E D I C A L H O M E ( P C M H ) A T T E S T A T I O N O F F A C I L I T Y C O M P L I A N C E
P A T I E N T C E N T E R E D M E D I C A L H O M E ( P C M H ) A T T E S T A T I O N O F F A C I L I T Y C O M P L I A N C E State of Wyoming, Department of Health, Division of Healthcare Financing 2015
User Guide Chronic Disease Management Tariffs e-form
User Guide Chronic Disease Management Tariffs e-form Page 1 of 15 Table of Contents Computer Requirements... 3 Accessing the e-form... 3 Are eforms Secure?... 4 Completing the Chronic Disease Management
.. Nuve. Wrinkle Treatment. User Guide Includes impor tant safety information. Read all instructions pri or to use.
.. Nuve Wrinkle Treatment User Guide Includes impor tant safety information. Read all instructions pri or to use. The dpl Nüve is intended for treatment of wrinkles, fine lines, and other effects of aging
Quick Reference. eivf Quick Reference Frequently Asked Questions 1
Quick Reference Quick Reference...1 Frequently Asked Questions...4 Where s the IUI schedule?...4 How do I schedule an IUI...4 How do I double-book an appointment?...4 How do I print lab schedules...4 How
Application to register with the Blind Foundation
Application to register with the Blind Foundation To register with the Blind Foundation, we need some information from your eye care specialist and some information from you. Please complete this form
Welcome to PGC Basketball! Now that you ve signed up, there are a few things you need to do to make sure you re ready... FORMS TO COMPLETE: Complete the Personal Information Sheet and Medical Release Form,
DASH Risk Assessment and MARAC Referral Form - Health
DASH Risk Assessment and MARAC Referral Form - Health REFERRAL FROM (NAME, AGENCY) TO LEAD AGENCY SOUTH YORKS POLICE TEL: 01142523682 / 0114252 3597 FAX: 01142523095 DATE: VICTIM S DETAILS NAME : DATE
PROFESSIONAL COMMUNICATIONS: COVER LETTERS, REFERENCES, S, and THANK YOUS
PROFESSIONAL COMMUNICATIONS: COVER LETTERS, REFERENCES, EMAILS, and THANK YOUS Professional Development Workshop Series Career Development and Internships Office (CDIO) careers@northpark.edu (773)244-5575
What is Smart 911? Smart911 is a service that may help someone to be safer and more prepared when an emergency happens.
Smart9-1-1 Assent Form for Adults with Intellectual Disabilities Organization: Contact Person: Address: City, State, Zip: Phone: Email: This form has words in it that might be new to you. If you hear any
Aetna HealthNetworkOnlyOpenAccess UT 01/01/2018
HealthNetworkOnlyOpenAccess UT 01/01/2018 Plan Name UT Peak Pref HNOnly 00 8/70 (0118) UT Peak Pref HNOnly 1000 8/70 (0118) UT Peak Pref HNOnly 100 8/70 (0118) UT Peak Pref HNOnly 2000 80/6 (0118) UT Peak
2015 Partners in Excellence Executive Overview, Targets, and Methodology
2015 Partners in Excellence Executive Overview, s, and Methodology Overview The Partners in Excellence program forms the basis for HealthPartners financial and public recognition for medical or specialty