Physician'S Orders And Certificate Of Medical Necessity Form

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Physician’s Orders and Certificate of Medical Necessity Form
XORDERING PHYSICIAN INFO
XNEW PATIENT
INFORMATION:
____________________________
PATIENT’S NAME: ______________________________________ MALE ______ FEMALE _____
DATE
ADDRESS: ___________________________________________ APT.# ____________________
___________________________________
PHYSICIAN’S NAME
CITY: _____________________________ STATE: _______________ ZIP: _________________
____________________________
HOME PHONE: ___________________________ WORK PHONE __________________________
PHYSICIAN’S PHONE
DATE OF BIRTH: _____________________ AGE ____ SOC. SECURITY # ____________________
________________________________________
ADDRESS
XPRIMARY INSURANCE
INFORMATION:
________________________________________
CITY
STATE
ZIP
PRIVATE/INDEMNITY ______
PPO _____
HMO ______
WORKERS COMPENSATION _______
________________________________________
MEDICAL FACILITY
PERSONAL INJURY ______
AUTO ______ MEDICARE ______
________________________________________
PRIMARY INSURANCE ________________________________
OEDERING FAX NUMBER
ADDRESS ________________________________ CITY __________________ STATE ________
________________________________________
DX / SYMPTONS
ZIP ___________ PHONE NUMBER ___________________ INSURED NAME ________________
________________________________________
GROUP NUMBER ________________ SOC. SECURITY # ________________________________
________________________________________
INSURED EMPLOYER ___________________________________________________________
XSECONDARY INSURANCE
INFORMATION:
________________________________________
PRIVATE/INDEMNITY ______
PPO _____
HMO ______
WORKERS COMPENSATION _______
XON-SITE SERVICES
ORDERED:
PERSONAL INJURY ______
AUTO ______ MEDICARE ______
PRIMARY INSURANCE ________________________________
EMG / NCV _____________________
ADDRESS _____________________________ CITY __________________ STATE __________
CONSULTATION _________________
ZIP ___________ PHONE NUMBER ___________________ INSURED NAME ________________
BOTOX ________________________
GROUP NUMBER ________________ SOC. SECURITY # ________________________________
INSURED EMPLOYER ___________________________________________________________
TRIGER POINT
INJECTIONS ____________________
XWORKER COMPENSATION AND OTHER INSURANCE
INFORMATION:
_________ BOTH ARMS
DATE OF INJURY ______ / ______ / _______________
_________ BOTH LEGS
ATTORNEY NAME _____________________________________________________________
________ LEFT ARM
ATTORNEY PHONE ___________________________ CLAIM NUMBER _____________________
________ LEFT LEG
CARRIER NAME ________________________ CARRIER PHONE __________________________
________ RIGHT ARM
XORDERING PHYSICIAN
STATEMENT:X
________ RIGHT LEG
I certify that I am ordering specified services for the above named patient. I, as the ordering physician for
services described in this request, certify that to my best knowledge, that the tests and any interpretation
________ NECK
required is medically necessary in order to provide information which will assist in the proper diagnosis
and/or treatment management for the above named patient. I understand that the tests ordered, and any
________ LUMBAR-SACRAL BACK
interpretation, that I receive are intended to supplement my diagnosis of this patient’s condition.
________ SHOULDER LEFT
________ SHOULDER RIGHT
______________________________________________________
SIGNATURE
REFERRED TO:
COMMUNITY NEUROLOGIC CENTER
2401 KANEVILLE RD., SUITE 8, GENEVA, IL 60134, TEL. 630-208-7735, FAX 630-208-6956

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