36C10X19Q0200-011.docx
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- Solicitation number
- 36C10X19Q0200
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36C10X19Q0200 Attachment F - Reviewer Template_MAN.docx
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Text version
CASE ID
MANAGEMENT REVIEW REQUEST
The documents, records, and other information contained herein, which resulted from Risk Management are confidential and privileged under the provisions of 38 U.S.C. § 5705, and its implementing regulations. This material cannot be disclosed to anyone without authorization as provided for by that law or its regulations. The statute provides for fines up to $20,000 for unauthorized disclosures.
Case ID:
Patient Name:
Practitioner to be reviewed:
Credential:
Service/Specialty:
Period to be reviewed:
Was standard of care Met?
· Yes
· No
Special Instructions:
Brief Clinical Summary/Case Overview:
Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph
Salient Features of the Case:
· Bulleted List
Analysis that supports decision:
Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph Paragraph
Reference, if applicable:
1. Numbered List
2. Numbered List
3. Numbered List
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