J-15 Treatment Summary Form.pdf

Treatment Appointment Summary World Trade Center National Responder Health Program

Patient Visit Date DOB Physician CPT Code (s) for Today's Visit:

*Please refer to ICD9 code list for covered diagnosis codes. A Secondary Diagnosis should only be selected if the associated primary diagnosis can be linked. *

Primary Diagnosis Secondary Diagnosis Referring Diagnosis: Do you concur with this diagnosis? Yes No

*If preliminary diagnosis is incorrect please indicate appropriate primary and secondary (if applicable) diagnoses above* Are you able to confirm the correlation between the responder's condition and WTC Exposures? Yes No Comments:

Assessment

Treatment Plan

Additional number/frequency of appointments requested:

Has an appointment been scheduled? No Yes Date:

Did today's appointment result in referrals to another specialty? Yes No

*If yes, please indicate ICD9 and/or CPT from the code lists provided and requested urgency as these referrals require prior authorization*

Referral Type Requested Urgency Emergent Urgent 1-2 Weeks Next. Appt

Referral Type Requested Urgency Emergent Urgent 1-2 Weeks Next. Appt Medication

Was medication prescribed at today's appointment? No Yes If Yes, please provide prescription information.

Medication Name: Duration Refills

Medication Name: Duration Refills

Medication Name: Duration Refills

Medication Name: Duration Refills

Medication Name: Duration Refills

Physician Signature Date:

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