CONFIDENTIAL PATIENT CASE HISTORY PLEASE COMPLETE THIS


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PATIENT HISTORY SHEET - CORA PHYSICAL THERAPY

I may revoke this authorization at any time by notifying CORA in writing to Attention Collections Manager, 1110 Shawnee Road, Lima, OH, 45805 of my intent to revoke this authorization. Pub on Wed, 20 Mar 2019 02:24:00 GMT
Source: https://www.coraphysicaltherapy.com/wp-content/uploads/2017/08/CORA-Patient-Form_English.pdf
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BEHAVIORAL HEALTH SERVICES 21-DAY INPATIENT DUAL DIAGNOSIS ...

Thank you for your interest in Behavioral Health Services (BHS) Dual Diagnosis Program. To initiate a referral, please complete the Dual Diagnosis Referral Application and have the patient complete the Pub on Tue, 19 Mar 2019 12:40:00 GMT
Source: https://www.brmc.com/files/DD%20Referral%20Packet%20February%202016.pdf
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PROVIDER’S COMPREHENSIVE PATIENT ASSESSMENT FORM (PAF ...

BlueCross BlueShield of Tennessee, Inc. is a Health plan with a Medicare contract. BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association Pub on Tue, 19 Mar 2019 14:06:00 GMT
Source: http://www.bcbst.com/providers/medicare-advantage/H7917_13_PAFINST_Web_Instructions_PAF.pdf
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JEFFERIES - PEER REVIEW 4 - ESTES PARK INSTITUTE HOME

HortySpringer Seminars Worksheet for Surgical/Procedure Review - 5 PATIENT MANAGEMENT YES NO N/A Was the physician's use of the following appropriate? Pub on Wed, 20 Mar 2019 16:35:00 GMT
Source: http://www.estespark.org/nu_upload/File/Conference%20Materials/2009-2010%20Materials/Jefferies%20-%20Legitimacy%20of%20Peer%20Review%20Attach%204%201-29.pdf
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MEMBER / PATIENT IDENTIFICATION MEMBER/PATIENT NAME

Jan 2017 Authorization to Use and Disclose Health Information . MEMBER / PATIENT IDENTIFICATION (please print) Member/Patient Name: _____ First Middle Last Pub on Tue, 19 Mar 2019 11:36:00 GMT
Source: https://www.maxorplus.com/sites/default/files/MaxorPlus%20-%20Authorization%20to%20Disclose%20Protected%20Health%20Information%20Form%20Jan2017.pdf
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY ...

CDPH 8641A (05/13) Page 2 of 4 VI. Patient History (See Appendix 5.0 for Further Details - Respond to All Questions) Pediatric Risk (Please Enter in Comments and Local/Optional Fields Section) After 1977 and before the earliest known diagnosis of HIV infection, this patient had: Sex with a male: Yes No Unknown Sex with a female: Injected non-prescription drugs: Pub on Tue, 19 Mar 2019 03:51:00 GMT
Source: http://www.sjcphs.org/disease/documents/20150429_HIV-AIDS%20Confidential%20Report%20form%20cdph8641a.pdf
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TO PREPARE FOR YOUR EXAM - COOPERAEROBICS.COM

To Prepare for Your Exam Please complete the following checklist Completethe following paperwork included in this packet and bring it to your exam Pub on Tue, 19 Mar 2019 14:49:00 GMT
Source: https://cooperaerobics.com/Downloads/Clinic/Cooper-Clinic-Patient-Packet-Revised.aspx
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CHRONIC ILLNESS BENEFIT APPLICATION FORM 2019

Malcor Medical Aid Scheme, registration number 1547. Administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised financial services provider. Pub on Tue, 19 Mar 2019 01:42:00 GMT
Source: https://www.malcormedicalaid.co.za/medicalschemes_za/malcor/web/linked_content/pdfs/chronic_illness_benefit.pdf
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PATIENT REGISTRATION INFORMATION - MYHEALTHRECORD

FINANCIAL POLICIES, TERMS, CONDITIONS AND RELEASES TCPA Consent: The Telephone Consumer Protection Act (TCPA) regulations define "prior express written consent”. I acknowledge under the TCPA that by providing my land line Pub on Sun, 17 Mar 2019 17:08:00 GMT
Source: https://myhealthrecord.com:9999/documents/1298/edb7f52c-c5e1-49d5-8de3-bdf75c07d779.pdf
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CHRONIC ILLNESS BENEFIT APPLICATION FORM 2019

Remedi Medical Aid Scheme. Registration number 1430 is administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07. Discovery Health (Pty) Ltd is an authorised financial services provider.Page 1 of 6 Pub on Wed, 20 Mar 2019 21:22:00 GMT
Source: http://www.yourremedi.co.za/medicalschemes_za/remedi/web/pdfs/cib_application_form.pdf
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