Soap Progress Note (Page 4 of 4) in pdf

Sections marked with  are mandatory

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Complete this form electronically at

Code»

SOAP Progress Note

Patient Name:

Provider/Practice:

Patient DOB:

Provider Credentials:

Patient Gender:

NPI:

Health Plan Member ID:

Health Plan Name:

Please do not mail the paper SOAP Note back to the return address.

…continued

Assessment

(Mandatory)

SIGNATURE, CREDENTIALS, EXAM DATE

(Mandatory)

Please note and initial changes to any of the below data

elements.

I have performed a face-to-face encounter for patient «FirstName» «LastName» and

assessed that the patient actively has, or is actively being treated for, the documented

medical conditions and warrant that all of the information I have provided to this

_________________________________

Medical Record is true and accurate. This document will be included with the patient’s

(MM/DD/YY)

Exam Date

other medical records.

(

)

Provider Signature

Provider/Practice

Provider Phone Number

(

)

Signature Date

Printed Provider Name and Credentials

Provider Fax Number

Provider E-mail Address

Inovalon is a business associate (as defined by the Health Insurance Portability and Accountability Act - “HIPAA”) of “Health Plan” and is ethically and legally bound to

protect, preserve, and maintain the confidentiality of any Protected Health Information (PHI) gathered from clinical records provided by medical practice locations,

pursuant to its contractual obligations to “Health Plan”. Inovalon neither directly delivers nor administers health benefits to patients; it provides “Health Plan” with

information useful for improving the quality of your patients’ care and health.

Per CMS requirements, all mandatory sections (

) on this medical record must be



completed. For your convenience, all assessments may also be completed online at

Inovalon Document ID:

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