Attachment G - Medical Advisory Opinion Template.pdf
PDF 174 KB Posted
- Attached to
- MLRM External Clinical Review BPA
- Solicitation number
- 36C10X24R0038
About this file
The provided document is a Medical Advisory Opinion Template that appears to be used in a federal contract opportunity. The template includes sections for the attorney's summary and allegations, the focus of review, specific questions for the reviewer, a chronology attestation, the reviewer's responses to the questions, a summary and overall conclusions, and the reviewer's credentials and specialty.
The related federal contract opportunity is for the Department of Veterans Affairs (VA) to establish multiple Blanket Purchase Agreements (BPAs) for external clinical review services. The scope includes peer review for quality management, management review, medical advisory opinions, executive summaries, reports, and inter-rater reliability studies. The performance period is five years, and quotes are due by July 02, 2024, at 10:00 AM ET. All responsible sources may submit a proposal, and the government will use simplified acquisition procedures for this procurement.
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Text version
CASE ID Attorney Case No
PRIVILEGED & CONFIDENTIAL – MEDICAL ADVISORY OPINION – NOT AN EXPERT OPINION
MEDICAL ADVISORY OPINION REPORT
Case ID:
Attorney Case No:
Patient Name:
Event date(s) to be reviewed:
Episode of Care:
Practitioner to be reviewed:
Credential:
Specialty:
ATTORNEY’S SUMMARY AND ALLEGATIONS:
DIRECTIONS:
FOCUS OF REVIEW:
SPECIFIC QUESTIONS FOR THE REVIEWER:
SPECIAL INSTRUCTIONS:
CHRONOLOGY ATTESTATION:
☐ The chronology in this Medical Advisory Opinion was generated by me. The chronology reflects the relevant information in the claimant’s electronic health record associated with this claim.
OR
☐ The chronology in this Medical Advisory Opinion was generated by a clinician other than me. I have verified the accuracy and completeness of this chronology and have not made modifications. The chronology reflects the relevant information in the claimant’s electronic health record associated with this claim.
OR
☐ The chronology in this Medical Advisory Opinion was generated by a clinician other than me. I have verified the accuracy and completeness of this chronology and have made modifications. The chronology reflects the relevant information in the claimant’s electronic health record associated with this claim.
ATTORNEY’S QUESTIONS & RESPONSES TO EACH:
Attachment G: Medical Advisory Opinion Template
CASE ID Attorney Case No
PRIVILEGED & CONFIDENTIAL – MEDICAL ADVISORY OPINION – NOT AN EXPERT OPINION
Q1. XXXXXXXX
RESPONSE:
Q2. XXXXXXXX
RESPONSE:
SUMMARY & REVIEWER’S OVERALL CONCLUSIONS:
REFERENCES, IF APPLICABLE:
REVIEWER’S CREDENTIAL & SPECIALTY:
All contract reviewers are required to provide an attestation that they are board certified, meet clinical qualification requirements, and have no conflict of interest, prior to being assigned to complete a VHA clinical review.
| Q1. XXXXXXXX |
| RESPONSE: |
| Q2. XXXXXXXX |
| RESPONSE: |
| SUMMARY & REVIEWER’S OVERALL CONCLUSIONS: |
| REFERENCES, IF APPLICABLE: |
| REVIEWER’S CREDENTIAL & SPECIALTY: |
| All contract reviewers are required to provide an attestation that they are board certified, meet clinical qualification requirements, and have no conflict of interest, prior to being assigned to complete a VHA clinical review. |
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