J-14 Non-Covered Conditions Recommendation Form.pdf

WORLD TRADE CENTER MEDICAL MONITORING & TREATMENT PROGRAM

NON-WTC COVERED CONDITIONS RECOMMENDATION FORM

WTC PROVIDER

Printed Name of Provider:

Office Telephone Number:

Fax Number:

PATIENT INFORMATION GENDER: MALE FEMALE

Patient Name (First/MI/Last):

Date of Birth (mm/dd/yyyy):

Patient WTC Number:

Street Address:

City:

State:

Zip Code:

Home Telephone Number:

Work Telephone Number:

Cell Telephone Number:

DIAGNOSIS CODES For Non-WTC Covered Conditions (Refer to ICD9 List for additional codes) Autoimmune

714.0 Rheumatoid Arthritis

710.0 Lupus

710.1 Scleroderma

Other___.__ Other___.__

Cancer

188.9 Bladder

208.9 Blood

162.9 Lung

Other___.__

Cardiac

401.9 Essential Hypertension

414.0 Coronary Artery Disease

785.2 Heart Murmur

Other___.__

Endocrine/Renal

250.0 Diabetes

585.9 Renal Disease

070.0 Viral Hepatitis

Other___.__

Gastrointestinal

535.5 Gastritis and Gastroduodenitis

Other___.__

Musculoskeletal

715.9 Osteoarthritis

716.1 Traumatic Arthropathy

716.5 Unspecified Polyarthritis

Other___.__ Other___.__ Other___.__

Other

278.01 Morbid Obesity

303.9 Alcohol Dependence

305.1 Tobacco use

Other___.__ Other___.__ Other___.__

FOR PATIENT FOLLOW-UP

WTC PROVIDER SUMMARY/RECOMMENDATION(S)

Your test results were not completely normal and may be an indication of <INSERT CONDITION> based on:

Medical History (describe)_______________________________________________________________________ Physical Signs (describe)_________________________________________________________________________ Abnormal Test(s) Results(describe) Labs___________ Chest x-ray__________ Other___________ Other (describe)________________________________________________________________________________

This is not a WTC covered condition so I encourage you to follow-up with your primary care provider for more testing: as soon as possible within 1-2 weeks at your convenience

WTC PROVIDER’S SIGNATURE

WTC Provider Signature:

Provider Number:

Date: ___/___/_____

White copy – WTC Medical Records *Pink copy – Patient

NON-WTC Covered Conditions