Medical Access Order (Mao) Request Form

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MEDICAL ACCESS ORDER (MAO) REQUEST FORM
Date:_______________
Region:_____________
Area/District Office:________________________
Telephone #:____________________ Fax #:___________________________________
1.
Name of Employer/Company to be Inspected/Evaluated:____________________
__________________________________________________________________
Address:__________________________________________________________
___________________________________________________________
___________________________________________________________
a.
Contact Person:_______________________________________________
Job Title:____________________________________________________
b.
Type of Company - Product:_____________________________________
c.
SIC/NAICS:_________________________________________________
d.
Number of Employees:_________________________________________
2.
Purpose of Inspection/Evaluation (Compliance Issues - BBP, Recordkeeping, etc.;
VPP Evaluation):______________________________________________
_________________________________________________________________
_________________________________________________________________
3.
Basis for Inspection/Evaluation (Complaint, Fatality, etc....; Pre-approval, Merit,
Star..):____________________________________________________________
__________________________________________________________________
__________________________________________________________________
4.
Date of Initial Inspection:_____________________________________________
Preliminary Findings:________________________________________________
__________________________________________________________________
__________________________________________________________________
5.
Period requested for Medical Records Access/Review: January 1, _______ to the
present date.
6.
Inspection - Medical Records Access/Review to Begin (approx.):_____________
Be Completed By:____________

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