INDEPENDENT MEDICAL EXAMINATION. Dr. Jeffery Luther
|
|
|
- Hilda Wade
- 8 years ago
- Views:
Transcription
1 INDEPENDENT MEDICAL EXAMINATION Dr. Jeffery Luther
2 What is an Independent Medical Exam? Objective and impartial medical exam Requested by workers compensation insurer or self insured provider Conducted by health care provider (MD or DO) who is not part of the worker s medical treatment team.
3 Who can perform an IME? MD or DO with unrestricted license Medical knowledge in a specific area pertinent to the case Experience, training, or credentials in the area of IMEs
4 Features of Report Worker s Compensation Motor Vehicle Injury or Personal Long Term Disability IME Types IME of Medical Injury IME Exams Conventional Medical Exam Level of History Detail Directed toward objective documentation, usually utilizes protocol for IR Directed toward objective documentation, sometimes utilizes protocol for IR Directed toward objective documentation, sometimes utilizes protocol for IR Directed toward diagnosis, rarely utilized protocol for IR Physical Exam Always Always Always Always Diagnosis Usually Often Often Rarely Causation Usually Sometimes No No Prognosis Often Often Often Often MMI Usually Often Often Rarely Impairment Rating Usually Sometimes No No Functional Often Often Often Rarely
5 Features of the IME Introduction History Record review Physical examination Other objective data (laboratory results, imaging) Opinions Impressions Discussion of diagnoses Comments on past medical treatment
6 Features of IME continues Comments on future treatment Prognosis As appropriate: MMI, Causation, Impairment Rating, Apportion Addressing specific questions
7 What happens during the exam? Provider identifies him/herself as an independent examining physician Verify the worker s identity Discuss the following: Remind the worker of the party who requested the exam Explain that the physician-patient relationship will not be established
8 What happens during the exam? Discuss the following: Tell the worker that information provided during the exam will be included in a report Review procedures that will be used during the examination Advise the worker that they may stop the procedure if it is beyond their abilities or becomes painful Allow the worker to ask questions
9 Who is present during the exam? The exam is limited to the examinee and the examiner. A chaperone of the appropriate gender may be present A translator may be required
10 History Chief complaint(s): symptoms and chronology. Pain: location, frequency, radiation, duration, and factors that aggravate or alleviate symptoms. Standardized pain or behavioral inventories Associated symptoms: weakness or neurologic complaints. Mechanism of injury Initial symptoms and their course. Response to treatment. Describe the symptoms before and after the subject incident.
11 History Continued Symptoms from before incident Subsequent injuries or episodes that have occurred since then incident. Current functional status: activities of daily living, work activities, sports, hobbies and social functioning. Occupational history: time off work, job duties relevant to current injury, with comparison of prior and subsequent job activities. Relevant past medical history: previous relevant injuries or conditions, other conditions or injuries requiring medical treatment. Personal, family, and social history when relevant. Review of Systems
12 References AIMEHI (2005). Standards for Independent Medical Examinations. Retrieved March 20 th, 2015 from
13 Physical Examination General appearance, behavior. Formal and informal observations : relationship or lack of relationship with other physical findings. Who was present: chaperone, translator, other participants. Affect, attitude, cooperation, and mental status. Pain behavior Use of assistive devices Vital signs as appropriate. Detailed clinical examination findings: pertinent positive and negative findings
Standards for Independent Medical Examinations
Standards for Independent Medical Examinations (AIMEHI Note: This article was published by the AMA, American Medical Association, in The Guides Newsletter November/December 2005 edition. The AMA published
D. Clinical indicators for psychiatric evaluation are established by one or more of the following criteria. The consumer is:
MCCMH MCO Policy 2-015 Date: 4/21/11 V. Standards A. A psychiatric evaluation shall be done as an integral part of the assessment process. It serves as the guide to the identification of medical and psychiatric
Intensive Outpatient Psychotherapy - Adult
Intensive Outpatient Psychotherapy - Adult Definition Intensive Outpatient Psychotherapy services provide group based, non-residential, intensive, structured interventions consisting primarily of counseling
CAUSALITY. G:medcost/acc/cur/2001 Level I Curriculum wwrev. 1/2008-13 -
CAUSALITY G:medcost/acc/cur/2001 Level I Curriculum wwrev. 1/2008-13 - Determining Causality in Workers Compensation Objectives: Define an authorized treating physician. List the principles of risk assessment
Accident/Assault/ Road Traffic Accident Questionnaire
It is important that you provide as much information as you can remember. Where specific dates are unknown, please give approximations. Please use the section on the back page for any additional notes.
February 2015 Guide to Providing Independent Medical Exams
February 2015 Guide to Providing Independent Medical Exams Workers Compensation Guide to Providing Independent Medical Exams The Workers Compensation Division (WCD) developed this guide for health care
FRESNO COUNTY EMPLOYEES RETIREMENT ASSOCIATION. Applicant Name: JOHN DOE Appointment Date: 01-01-10
FRESNO COUNTY EMPLOYEES RETIREMENT ASSOCIATION REFERRAL FOR INDEPENDENT MEDICAL EXAMINATION Applicant Name: JOHN DOE Appointment Date: 01-01-10 Time: 3:00 p.m. Date Name of Doctor Address Dear Dr.. On
Stuart B Black MD, FAAN Chief of Neurology Co-Medical Director: Neuroscience Center Baylor University Medical Center at Dallas
Billing and Coding in Neurology and Headache Stuart B Black MD, FAAN Chief of Neurology Co-Medical Director: Neuroscience Center Baylor University Medical Center at Dallas CPT Codes vs. ICD Codes Category
Patient Progress Note & Dictation Standard
Objective: The patient progress note serves as a basis for planning patient care, documenting communication between the health care provider and any other health professional contributing to the patient's
The file and the documentation should create a clean chronological record of the patient and their interactions with the provider.
Documentation and Coding Guidelines for Athletic Trainers Table of Contents What is documentation and why is it important? Documentation and SOAP What do payers want and why? General guidelines of medical
WORKERS COMPENSATION INTAKE FORM
WORKERS COMPENSATION INTAKE FORM related injury? No Yes INSURANCE INFORMATION RELEASE By clicking this box,i hereby authorize ABA Physical Therapy Associates to release to my Insurance company/attorney,
INDEPENDENT MEDICAL EXAM (IME)
INDEPENDENT MEDICAL EXAM (IME) As you know, the purpose of the Insurance Company is not to obtain an impartial review, but to obtain a medical opinion which could justify the discontinuance and/or denial
Worker s Compensation Intake Form
Worker s Compensation Intake Form Patient Information: Name Home Phone Address Work Phone Social Security No. Date of Birth Sex Male Female Height Weight lbs Occupation Marital Status Employer No of Children
Mental Disorders (Except initial PTSD and Eating Disorders) Examination
Mental Disorders (Except initial PTSD and Eating Disorders) Examination Name: Date of Exam: SSN: C-number: Place of Exam: The following health care providers can perform initial examinations for Mental
Policy for Documentation
Policy for Documentation act.org 2015 by ACT, Inc. All rights reserved. 3836 Introduction The ACT Policy for Documentation contains information individual examinees, professional diagnosticians, and qualified
MENTAL IMPAIRMENT RATING
MENTAL IMPAIRMENT RATING Lev.II Curriculum Rev. 6/09 155 OBJECTIVES MENTAL AND BEHAVIORAL DISORDERS 1. Identify the axes used in the diagnostic and statistical manual of mental disorders - DSM. 2. Understand
Personal Injury Intake Form
Personal Injury Intake Form Patient Information: Name Home Phone Address Work Phone Cell Phone Date of Birth Social Security # Sex Male Female Height Weight lbs Occupation Marital Status Employer No of
CPSM DRAFT STATEMENT ON PHYSICIAN ASSISTED DYING OCTOBER 15, 2015
CPSM DRAFT STATEMENT ON PHYSICIAN ASSISTED DYING OCTOBER 15, 2015 BACKGROUND The Supreme Court of Canada (SCC) declared that as of February 6, 2016 it is legal for a physician to assist a competent adult
Patient Information. Date: Date of Birth: / / Name: Social Security: _- - Address: Street City State Zip
Personal Insurance Intake Form Patient Information Date of Birth: / / Social Security: _- - Address: Street City State Zip Email Address: Home Phone: Sex: M or F Work Phone:. Cell Phone: Height: Weight:
Notice of Privacy Practices
Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed, and how you may obtain access to this information. Please review it carefully. OMAC respects
Driver indicated a loss or impairment of consciousness within last: 6 months 12 months or more Date: / /
PHYSICIAN S STATEMENT OF EXAMINATION Michigan Department of State Driver Assessment and Appeal Division P.O. Box 30196, Lansing, Michigan 48909-7696 Phone: (517) 335-7051; Fax: (517) 335-2189; E-mail:
Optum By United Behavioral Health. 2015 Florida Medicaid Managed Medical Assistance (MMA) Level of Care Guidelines
Optum By United Behavioral Health 2015 Florida Medicaid Managed Medical Assistance (MMA) Level of Care Guidelines (TBOS) Therapeutic behavioral on-site services are intended to prevent members under the
Back Pain Measure Group Patient Visit Form
Please complete the form below for 20 unique patients meeting the patient sample criteria for the measure group. For the Back Pain Measure Group, patients you enter that have a diagnosis of back pain,
Impact of Psychiatric Claim on MMI and PPD
Impact of Psychiatric Claim on MMI and PPD Presented by: Kevin P. Kourofsky, Esq. Dr. Aryeh Klahr Paul Jahn Brian S. Trick January 16, 2014 Case Study, Part One Peter Piper, a pepper picker and packer
How To Cover Occupational Therapy
Guidelines for Medical Necessity Determination for Occupational Therapy These Guidelines for Medical Necessity Determination (Guidelines) identify the clinical information MassHealth needs to determine
DD Procedural Codes for Administrative Examinations **To be used solely by DD staff**
DD Procedural Codes for Administrative Examinations **To be used solely by DD staff** Overview An Administrative Examination is an evaluation required by the Department of Human Services (DHS) to help
INITIAL DISABILITY CLAIM FORM Policyholder s Statement
INITIAL DISABILITY CLAIM FORM Policyholder s Statement Failure to complete all sections may result in a delay in processing this claim. CAF001DI-13-v4 INITIAL DISABILITY CLAIM FORM Policyholder s Statement
PA Federation of Injured Workers Independent Medical Exam (I.M.E.)
PA Federation of Injured Workers Independent Medical Exam (I.M.E.) As you know, the reason a worker s compensation insurer/self-insured employer uses an Independent Medical Exam is not to obtain an impartial
MEDICAL MUTUAL Self-Assessment Form
MEDICAL MUTUAL Self-Assessment Form PURPOSE: The purpose of the self-assessment form is to highlight those areas within the non-clinical aspect of office practice including documentation of medical records,
Critical Illness Claim - Physician s Statement Multiple Sclerosis
AVIVA LTD 4 Shenton Way #01-01, SGX Centre 2, Singapore 068807 Telephone: 6827 7988 Fax: 6827 7900 Company Reg. No. 196900499K Critical Illness Claim - Physician s Statement Multiple Sclerosis SECTION
Changes for Master s-level Psychotherapists
Update December 2010 No. 2010-114 Affected Programs: BadgerCare Plus Standard Plan, BadgerCare Plus Benchmark Plan, Medicaid To: Advanced Practice Nurse Prescribers, HealthCheck Other Services Providers,
E&M Coding- It s All About The Documentation
E&M Coding- It s All About The Documentation Presented for Anthem Blue Cross and Blue Shield By: Penny Osmon, BA, CPC Coding & Reimbursement Educator WI Medical Society Wisconsin Medical Society, Copyright
36 Interviewing the Patient, Taking a History, and Documentation
CHAPTER 36 Interviewing the Patient, Taking a History, and Documentation Learning Outcomes 36.1 Identify the skills necessary to conduct a patient interview. 36.2 Implement the procedure for conducting
Creditor Disability Claim Application Kit
Life and Health Claims Dept. Creditor Disability Claim Application Kit The Application Kit contains: an instruction sheet plus forms that need to be completed in order to apply for disability benefits;
Rule 5.2 Definitions. For the purpose of Chapter 5 only, the following terms have the meanings indicated:
Part 2635 Chapter 5: Practice of Telemedicine Rule 5.1 Preamble. These regulations are intended to authorize M.D. and D.O. licensees of the Mississippi State Board of Medical Licensure to practice telemedicine
Template Medical-Legal Report -Workers Compensation
California Orthopaedic Association Template Medical-Legal Report -Workers Compensation This document is presented as a template of the required elements of an orthopaedic QME/AME report. It is provided
DISABILITY CLAIM APPLICATION FORMS For Standard / Partial Payment and Dismemberment Plans
DISABILITY CLAIM APPLICATION FORMS For Standard / Partial Payment and Dismemberment Plans INSTRUCTIONS ALL OF THE FOLLOWING PROPERLY COMPLETED FORMS ARE ESSENTIAL TO THE PROMPT PROCESSING OF YOUR DISABILITY
FREQUENTLY ASKED QUESTIONS
FREQUENTLY ASKED QUESTIONS 1. I have been practicing for several years and my degree is not in athletic training. Do I need to provide transcripts and a certification of education with my application?
Informed Consent for Physical Therapy Services
Informed Consent for Physical Therapy Services Physical therapy is a patient care service that is provided in order to manage a wide variety of conditions. Services are provided to individuals of all ages
Evaluation and Management Services Documentation and Level of Service
Evaluation and Management Services Documentation and Level of Service The purpose of this article is to remind providers that medical necessity and the patient s condition are the foundation for correctly
HORIZON PHYSICAL THERAPY 9154 ESTATE THOMAS ST. THOMAS V.I 00802 (340)776-7667 P (340)714-1891 F WELCOME
HORIZON PHYSICAL THERAPY 9154 ESTATE THOMAS ST. THOMAS V.I 00802 (340)776-7667 P (340)714-1891 F WELCOME We are pleased you have chosen us for your physical therapy needs. Our office is committed to providing
IF IN DOUBT, SIT THEM OUT.
IF IN DOUBT, SIT THEM OUT. Scottish Sports Concussion Guidance: Grassroots sport and general public Modified from World Rugby s Guidelines on Concussion Management for the General Public Introduction The
Initial Evaluation for Post-Traumatic Stress Disorder Examination
Initial Evaluation for Post-Traumatic Stress Disorder Examination Name: Date of Exam: SSN: C-number: Place of Exam: The following health care providers can perform initial examinations for PTSD. a board-certified
How you will benefit by implementing an early reporting system
Introduction How you will benefit by implementing an early reporting system Early reporting and action for musculoskeletal discomfort and pain directly assists workplaces wishing to prevent and manage
Focus on Assessment. Teaching Pain Assessment and Management: Pearls for Caring for Patients with Pain. #1. Pain is a Universal Experience.
Teaching Pain Assessment and Management: Pearls for Caring for Patients with Pain Jennifer Parsons, FNP Duke Pain Medicine Adaptive Teaches us about our environment Demands attention Can be all consuming
Optum By United Behavioral Health. 2015 New Jersey Managed Long-Term Services and Support (MLTSS) Medicaid Level of Care Guidelines
Optum By United Behavioral Health 2015 New Jersey Managed Long-Term Services and Support (MLTSS) Medicaid Level of Care Guidelines (AMHR) AMHR provides services in/by a licensed community residence. Services
BACK PAIN MEASURES GROUP OVERVIEW
2014 PQRS OPTIONS F MEASURES GROUPS: BACK PAIN MEASURES GROUP OVERVIEW 2014 PQRS MEASURES IN BACK PAIN MEASURES GROUP: #148. Back Pain: Initial Visit #149. Back Pain: Physical Exam #150. Back Pain: Advice
Medical Records Analysis
Medical Records Analysis Karen A. Mulroy, Partner Evans & Dixon, L.L.C. The analysis of medical legal issues posed in any case can be complicated, requiring some close reading and detective work to both
Documentation Guidelines for Physicians Interventional Pain Services
Documentation Guidelines for Physicians Interventional Pain Services Pamela Gibson, CPC Assistant Director, VMG Coding Anesthesia and Surgical Divisions 343.8791 1 General Principles of Medical Record
Guide for Filing WorkSafeBC Mental Disorder Claims
Canadian Union of Public Employees Guide for Filing WorkSafeBC Mental Disorder Claims WCB Advocacy Department BC Regional Office Tom McKenna, National Representative, WCB Advocacy Nothing in this Guide
Collaborative Practice Agreement for Nurse Practitioner Management of Patients in the Specialty of Pediatric Critical Care
Collaborative Practice Agreement for Nurse Practitioner Management of Patients in the Specialty of Pediatric Critical Care Purpose Section I Introduction/Overview This document authorizes the nurse practitioner
INTRUST SUPER PERSONAL ACCIDENT AND SICKNESS CLAIM FORM
1 of 7 INTRUST SUPER PERSONAL ACCIDENT AND SICKNESS CLAIM FORM This claim form consists of 3 parts and all sections must be completed in full. Section A Claimant Statement The claimant is to complete all
Forms designed to collect this information will help staff collect all pertinent information.
1 CPT AUDIT TOOL INSTRUCTIONS The Nursing Consultants from the Public Health Nursing and Professional Development Unit based on multiple Evaluation & Management audits across the state have developed these
form claim Beazley AMIST Super Income Protection Australian Income Protection A Beazley Group company
Beazley AMIST Super Income Protection claim form Australian Income Protection A Beazley Group company Australian Income Protection Pty Ltd AFS No 289089 Beazley AMIST Super Income Protection Claim form
North Florida Medical Centers, Inc. Notice of Information Practices
North Florida Medical Centers, Inc. Notice of Information Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
The 16 th Annual Pain Management Symposium Caesar s Palace, Las Vegas, Nevada. Disability Assessment 6:00 PM Tuesday, February 19, 2014.
The 16 th Annual Pain Management Symposium Caesar s Palace, Las Vegas, Nevada Disability Assessment 6:00 PM Tuesday, February 19, 2014 Daniel J. Leizman, MD Physical Medicine & Rehabilitation Staff, Pain
Medical College of Georgia Augusta, Georgia School of Medicine Competency based Objectives
Medical College of Georgia Augusta, Georgia School of Medicine Competency based Objectives Medical Knowledge Goal Statement: Medical students are expected to master a foundation of clinical knowledge with
Interviewing a Social Work Candidate Questions and Suggested Responses
Interviewing a Social Work Candidate Questions and Suggested Responses Selecting the best candidate for any position is important - time spent prior to hire may save time wasted on an improper hire. Asking
Intermedix Inc. EMR 2006 Data Element Name. Compliant. Data Number. Elements
D01_01 EMS Agency X D01_02 EMS Agency D01_03 EMS Agency State X D01_04 EMS Agency County X D01_05 Primary Type of Service D01_06 Other Types of Service D01_07 Level of Service X D01_08 Organizational Type
A Hidden Challenge in WORKERS COMPENSATION
Published by the Public Risk Management Association www.primacentral.org A Hidden Challenge in WORKERS COMPENSATION APRIL 2015 A Hidden Challenge in WORKERS COMPENSATION By Dr. John Robinton 2 PUBLIC RISK
a) Each facility shall have a medical record system that retrieves information regarding individual residents.
TITLE 77: PUBLIC HEALTH CHAPTER I: DEPARTMENT OF PUBLIC HEALTH SUBCHAPTER c: LONG-TERM CARE FACILITIES PART 300 SKILLED NURSING AND INTERMEDIATE CARE FACILITIES CODE SECTION 300.1810 RESIDENT RECORD REQUIREMENTS
2013 PQRS Measures Groups Specifications Manual BACK PAIN MEASURES GROUP OVERVIEW
2013 PQRS OPTIONS F MEASURES GROUPS: CLAIMS, REGISTRY BACK PAIN MEASURES GROUP OVERVIEW 2013 PQRS MEASURES IN BACK PAIN MEASURES GROUP: #148. Back Pain: Initial Visit #149. Back Pain: Physical Exam #150.
EMERGENCY MEDICINE PATIENT PRESENTATIONS: A How-To Guide For Medical Students
EMERGENCY MEDICINE PATIENT PRESENTATIONS: A How-To Guide For Medical Students Kerry B. Broderick, MD David E. Manthey, MD Wendy C. Coates, MD For the SAEM Undergraduate Education Committee Patient presentation
Workplace Safety and Insurance Board (WSIB)
Workplace Safety and Insurance Board (WSIB) Dr. L. Grbac March 25, 2013 1 ASSESSMENT AND TREATMENT RESOURCES Programs of Care Specialty Clinics Low Back Expert Physician Examiner Assessments Regional Evaluation
Goodman Fielder Income Protection Claim Form
Section A Claimant s Section Goodman Fielder Income Protection Claim Form INCOME PROTECTION CLAIMS In order to alleviate any delay in the processing time of your claim, please ensure the following: The
Total and Permanent Disability claim form
Total and Permanent Disability claim form 1. Notice Of Claim Written notice of claim must be given to AXA Life within 90 days from the date of disability certified by a specialist in the relevant field.
Administrative Guide
Community Plan KanCare Program Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide Doc#: PCA15026_20150129 UHCCommunityPlan.com Welcome to UnitedHealthcare This administrative
Joint Effort Rehab, LLC New Patient Forms
Patient Information DEMOGRAPHICS Joint Effort Rehab, LLC First Name: MI: Last Name: Sex: M F Home Phone: Work Phone: Cell Phone: SSN: of Birth: Email: Referring Physician: Employer Name: Primary Insurance
ICD-9 Basics Study Guide
Board of Medical Specialty Coding ICD-9 Basics Study Guide for the Home Health ICD-9 Basic Competencies Examination Two Washingtonian Center 9737 Washingtonian Blvd., Ste. 100 Gaithersburg, MD 20878-7364
DATE DUE: RESIDENT NAME: DATE(S) OF COMPLETION: STAFF COMPLETING RESIDENT REVIEW:
483.25 QUALITY OF CARE F309 CARE AND SERVICES FOR RESIDENT WITH PAIN Based on QIS CE Pathway CMS-20076 - Pain Recognition and Management http://www.aging.ks.gov/manuals/qismanual.htm Use of this tool is
Function First Physical Therapy, P.C. Patient Intake Form
Patient Intake Form Patient Information: Last Name: First Name: Sex: Date of Birth: SS#: - - Address: City: State: Zip Code: Work#: ( ) - Home#: ( ) - Email: Mobile#: ( ) - Marital Status: Single Married
Maritime Super Income Protection Claim Form
Maritime Super Income Protection Claim Form INCOME PROTECTION CLAIMS In order to alleviate any delay in the processing time of your claim, please ensure the following: The claim form is returned with all
An IME Is A Broad Concept
The Effective Use Of IME And Second Opinion Exams In New Jersey Workers Compensation Cases By Lora V. Northen, Esq. lnorthen@capehart.com 856-914-2070 October 29, 2015 @ 2015 Capehart & Scatchard, P.A.
SUMMARY DECISION NO. 70/98. Delay (treatment); Kienbock's disease.
SUMMARY DECISION NO. 70/98 Delay (treatment); Kienbock's disease. A construction worker injured his wrist while moving a plank on September 25, 1991. He continued working and did not seek medical treatment
Optum By United Behavioral Health. 2015 Florida Medicaid Managed Medical Assistance (MMA) Level of Care Guidelines
Optum By United Behavioral Health 2015 Florida Medicaid Managed Medical Assistance (MMA) Level of Care Guidelines (PSR) services combine daily medication use, independent living and social skills training,
How To Change The Law On Workers Compensation
Overview 2013 Changes to the Tennessee Workers Compensation Act On April 29, 2013 Tennessee Governor Bill Haslam signed into law the Tennessee Workers Compensation Reform Act of 2013 (SB200/HB194). This
CLAIMS A basic understanding
CLAIMS A basic understanding Samantha L. Boggess, CWCP Director of Claims Services, OIC Reporting a Claim Who is responsible? Injured Employee/Claimant 2 WV Code 23-4-1a Report of Injuries by Employee
EXCEL PHYSICAL THERAPY, INC.
EXCEL PHYSICAL THERAPY, INC. Medical History Form Name: Date of Birth: Date: Are you employed? YES NO Right Handed Left Handed If NO, last day worked? Do you smoke? YES NO #of packs/day Occupation: Height:
Athens Technical College Student Support Disability Services 800 U.S. Highway 29 North Athens, GA 30601-1500 706-355-5006 / jfelts@athenstech.
Athens Technical College Student Support Disability Services 800 U.S. Highway 29 North 706-355-5006 / Dear Athens Technical College Applicant/Student: Thank you for contacting the Disability Services Office
Claim Filing Instructions & Claim Form
Claim Filing Instructions & Claim Form Please follow these instructions prior to filing a claim and when completing the Claim Form. Assistance is also available from the IMG Customer Service Department
Clinical negligence. Grounds
Clinical negligence Clinical negligence occurs when the care or treatment the Claimant received from a health service provider was below the standard that is expected. This test was established in the
DATE OF BIRTH SOCIAL SECURITY (Last 4 digits): SEX: Male Female
PATIENT DATA SHEET PATIENT INFORMATION Please complete this form in its entirety prior to your first visit. Also, please bring your insurance information and/or cards to our office at your first visit.
RESEARCH SUBJECT INFORMATION AND CONSENT FORM
1 1 1 1 1 1 1 0 1 0 1 0 RESEARCH SUBJECT INFORMATION AND CONSENT FORM TITLE: PROTOCOL NR: SPONSOR: INVESTIGATOR: WIRB VCU tracking number This template is based on a drug or device research study. The
Registered Professional Nurse
Registered Professional Nurse Job Description- A Southern Healthcare Agency Registered Nurse is a competent, conscientious, and a dependable member of the professional health care team. The nurse functions
Clinical Negligence. Investigating Your Claim
www.lees.co.uk Clinical Negligence Investigating Your Claim Lees Solicitors LLP 44/45 Hamilton Square Birkenhead Wirral CH41 5AR Tel: 0151 647 9381 Fax: 0151 649 0124 e-mail: newclaim@lees.co.uk 1 The
Accident/Illness Claim
QBE INSURANCE (AUSTRALIA) LIMITED ABN 78 003 191 035 Accident/Illness Claim The issue of this form does not constitute an admission of liability on the part of the insurer. Please complete all sections
RULES OF THE ALABAMA BOARD OF MEDICAL EXAMINERS CHAPTER 540-X-15 TELEHEALTH. Table of Contents
RULES OF THE ALABAMA BOARD OF MEDICAL EXAMINERS CHAPTER 540-X-15 TELEHEALTH Table of Contents 540-X-15-.01 Purpose 540-X-15-.02 Telehealth Medical Services by Physicians According to Licensure Status 540-X-15-.03
DOCUMENTATION TEMPLATES. All patient care reports should include the following information in the narrative:
DOCUMENTATION TEMPLATES All patient care reports should include the following information in the narrative: Patient Data: -Chief Complaint -Mechanism of injury/nature of illness -Associated signs and symptoms/pertinent
PERSONAL ACCIDENT CLAIM FORM - MEMBERS
Pony Club Insurance Scheme PERSONAL ACCIDENT CLAIM FORM - MEMBERS Please read this page before completing the Claim Form Dear Member Thank you for your Claim Form request. This letter contains important
PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY / PROCEDURE:
PARTNERSHIP HEALTHPLAN OF CALIFORNIA POLICY/PROCEDURE Policy Number: MCUP3003 (previously UP100303) Reviewing Entities: Credentialing IQI P & T QUAC Approving Entities: BOARD CEO COMPLIANCE FINANCE PAC
Sports Injury Claim Form
Sports Underwriting Australia Sports Injury Claim Form Sports Underwriting Australia Claims Department PO Box 2717, Taren Point. NSW, 2229 Tel: 1300 363 413 Fax: 02 9524 9003 Email: paclaims@sportsunderwriting.com.au
Medical Report Prepared for The Court on
Medical Report Prepared for The Court on Mr Sample Report Claimant's Address Claimant's Date of Birth Instructing Party Instructing Party Address Instructing Party Ref Solicitors Ref Corex Ref 1 The Lane
Be submitted in a standard format as per the attached template. Be as clear and concise as possible
Guidelines for Claimant s Practitioner InjuriesBoard.ie is an independent Statutory Body. Our objective is to ensure that people claiming for injuries sustained in an accident have their compensation assessed
EMS Patient Care Report Navigation Logic for Record Creation
EMS Patient Report Navigation Logic for Record Creation This document serves to provide specifications regarding data entry and data element completion requirements for PreMIS Version 2 web-based application
Accident/Illness Claim
QBE INSURANCE (AUSTRALIA) LIMITED ABN 78 003 191 035 Accident/Illness Claim The issue of this form does not constitute an admission of liability on the part of the insurer. Please complete all sections.
New Patient Form Please print clearly
New Patient Form Today s Date: Name: Last First MI Preferred name to be called: Email: Address: Street City State Zip DOB: Age: Sex: SSN#: - - Please check a box for the preferred # to call to confirm
Premera s definition of Medical Necessity is written in your PREMERAFirst Provider Contract Part 1.08.
Premera and the Washington State Chiropractic Association (WSCA) worked closely to release the following positions focused on several issues centered on the practice of chiropractic care in the state of
1 Risk Factors for Prolonged Disability After Whiplash Injury: A Prospective Study. Spine: Volume 30(4), February 15, 2005, pp 386-391
1 Risk Factors for Prolonged Disability After Whiplash Injury: A Prospective Study Spine: Volume 30(4), February 15, 2005, pp 386-391 Gun, Richard Townsend MB, BS; Osti, Orso Lorenzo MD, PhD; O'Riordan,
POLICY NUMBER 2003-17-B JULY 8, 2014
POLICY NUMBER 2003-17-B JULY 8, 2014 POLICY: PATIENT RIGHT TO REQUEST COPIES OF HIS/HER MEDICAL/ DENTAL/RESEARCH AND/OR BILLING RECORD (Privacy & Security of Protected Health Information (PHI)) PURPOSE:
Physical Therapy. Physical Therapy Payment Policy Policy number M.RTH.02.120301 effective 10/01/2015. Page 1
Physical Therapy I. Policy University Health Alliance (UHA) will reimburse for physical therapy when it is determined to be medically necessary and when it meets the medical criteria guidelines (subject