Healthcare Documents

This file contains a Physician's Treatment Summary Form for accident, cancer, and/or sickness. It guides users on registering, submitting outpatient treatment, or surgeries. The form includes necessary fields for patient, physician, and treatment details.

The Person-Centered Service Plan Template is designed to help individuals outline their preferences, strengths, goals, and needs while identifying available services. It is used in accordance with Person-Centered Service Planning Guidelines. The template allows users to document necessary details, unmet service needs, and informal supports.

This file is used to process appeals for non-participating providers with Wellcare. Complete all required fields and submit with necessary medical documentation. Ensure proper authorization and documentation are included.

This file is used for enrolling in the RemiStart® Patient Rebate Program for REMICADE® medication. It includes detailed instructions for eligibility and submission. Ensure to fill out all required sections accurately.

This file is the Certificate of Live Birth form from the Tennessee Department of Health. It includes fields for child's information, mother's and father's details, and medical information. It is used for registering the birth of a child in Tennessee.

This form is used to collect information to determine third-party liability for injuries requiring medical care. It allows the United States to recover medical expenses from the party responsible for the injury. Failure to complete this form will result in delays or denial of your TRICARE claim.

This form allows parents or guardians in Louisiana to claim an exemption from immunization requirements for their child due to medical, religious, or philosophical reasons. It must be signed by a parent or guardian and an authorized district or school representative. The form outlines the conditions under which a child may be excluded from attendance during an outbreak.

This file is a request form for obtaining an official immunization record from the Michigan Department of Health and Human Services. It contains fields for personal information, requestor information, address details, and signature. Follow the instructions to complete and submit the form.

This file contains the necessary form for submitting prior authorization requests to CalOptima. It includes sections for prescriber and patient information, medication details, and justification statements. Follow the instructions to complete the form accurately.

The Lower Extremity Functional Scale (LEFS) is a questionnaire with 20 questions about a person's ability to perform everyday tasks. It helps clinicians measure patients' initial function, ongoing progress, and outcome. It is useful for evaluating functional impairment and monitoring patient progress over time.

This document provides details and instructions for enrolling in Firstsource's Healthcare Cloud Financial Assistance services. It includes an overview of the process and key benefits. The document also offers guidelines for both patients and hospital staff.

The CAGE Substance Abuse Screening Tool helps clinicians identify potential substance abuse issues. Using a series of key questions, this tool aids in determining whether substance abuse exists and needs to be addressed. It includes instructions for both alcohol and drug use assessment.