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CONSULTATION/REFERRAL REQUEST FORM - Home -- American Academy ...

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CONSULTATION/REFERRAL REQUEST FORM - Home -- American Academy ...

CONSULTATION/REFERRAL REQUEST FORM To: Consultant . Name: _____ Address: _____ Phone/fax: _____ From: Primary physician

http://www.aafp.org/fpm/2007/1100/fpm20071100p38-rt1.doc

Date added: March 4, 2013 - Views: 150

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A Log to Track Referrals and Test Results

( the referring physician lacks a system to track referrals to ensure follow-up. The log form on the next page helps physicians and staff track referrals ... the date, and the referral destination. When the report or consultation letter returns, staff records the date it is received and ...

http://www.miec.com/Portals/0/WordTemplates/A%20Log%20to%20Track%20Referrals%20and%20Test%20Results.doc

Date added: October 2, 2012 - Views: 48

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REFERRAL AGREEMENT - American Academy of Family Physicians

• A Women’s Health physician will be available during clinic hours for emergent questions, ... Physicians in Women’s Health and Family Medicine will use the ANMC Referral and Consultation Form to communicate requests for services between clinics.

http://www.aafp.org/fpm/2002/0300/fpm20020300p39-rt1.doc

Date added: February 7, 2012 - Views: 168

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FEEDBACK - AAP.org

physician referral and feedback form template. strategies for system change in children’s . mental health: a chapter action kit. Date: _____ ( ) Initial ( ) Follow Up

http://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Mental-Health/Documents/PhyRefFeedFrm.doc

Date added: March 3, 2013 - Views: 23

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SAMPLE : REFERRAL FORM (Universal) - New York Statewide ...

SAMPLE: REFERRAL FORM (Universal) Author: Exceptional Children Last modified by: sschoess Created Date: 12/29/2004 12:59:00 PM Company: Monroe 2-Orleans BOCES Other titles: SAMPLE: REFERRAL FORM (Universal) ...

http://www.schoolhealthservicesny.com/uploads/Referral%20Form%20(Universal)%20-%20Memo%20to%20Parent.doc

Date added: November 1, 2011 - Views: 301

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medpointmanagement.com

HCLA Direct Referral Form 2014.docx. DIRECT REFERRAL FORM. c/o MedPOINT Management. P.O. Box 570590, Tarzana CA 91357. Phone: 818-702-0100 ♦ Fax: 818-702-1744. FORM MUST BE FULLY COMPLETED BY PRIMARY CARE PHYSICIAN’S (PCP) OFFICE.

http://medpointmanagement.com/Forms/DirectReferralForms/DirectReferrals/HCLA%20Direct%20Referral%20Form.doc

Date added: May 30, 2012 - Views: 9

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BLOOD PRESSURE SCREENING REFERRAL FORM - Roman Catholic ...

Physician’s Report of Blood Pressure Examination. Student’s Name: _____ Examination Findings ... BLOOD PRESSURE SCREENING REFERRAL FORM Author: Susan Willis Last modified by: swillis Created Date: 6/17/2008 11:12:00 PM

http://www.diocesetucson.org/DOT%20School%20Health%20Manual%20Appendices/AppK4.doc

Date added: June 27, 2012 - Views: 8

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Suggested Standing Order Template - NC Public Health Nursing

physician. 3. Criteria for Calling the Physician: ... State any follow up testing, rescreening or referral which is routinely required. Legal Authority: ... Suggested Standing Order Template ...

http://ncpublichealthnursing.org/Standing%20Order%20Template.doc

Date added: September 23, 2011 - Views: 27

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OCCUPATIONAL THERAPY REFERRAL FORM - USC Occupational Science ...

OCCUPATIONAL THERAPY REFERRAL FORM. Patient Name: Phone: Address: Diagnosis: ICD-9: Secondary Diagnosis: ICD-9: History/Precautions: Physician’s Name: Phone: Address: Email: NPI#:

http://ot.usc.edu/images/uploads/General_Referral_Form.doc

Date added: November 10, 2011 - Views: 21

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NURSE PRACTITIONER AND PHYSICIAN AGREEMENT

Physician will not be obligated or expected to recruit or refer patients to the nurse practitioner. Nurse practitioner will provide physician will appropriate tax forms at the end of the year. Nurse practitioner will pay $250.00 for 32 hours per month of office space and consultation.

http://npfreebies.com/NP_Physician%20Employment%20Agreement.doc

Date added: October 10, 2011 - Views: 43

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Sample Letter for Closing Your Medical Practice

In the alternative, you may call _____ (Physician Referral Service/County Medical Society) ... I am including a medical record request form that requires your signature and identification of the physician selected.

http://www.capphysicians.com/sites/default/files/file_attach/Closing%20Your%20Medical%20Practice%20SAMPLE%20LETTER_0.doc

Date added: May 20, 2013 - Views: 18

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PSA Intake & Referral Form

Physician Orders Physician Orders Change in equipment/supplies Discharge from Hospital Lab Report Other: Discussion Follow up required: Yes No Plan Employee Name/ Title Signature Abiding Home Health. Intake Created on 7/12/2006 ... PSA Intake & Referral Form ...

http://abidingforms.com/uploads/Communication_Note_-_Telephone_Template.dot

Date added: August 16, 2013 - Views: 7

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Sample Letter for Discontinuing Patient Care

You may call _____(Physician Referral Service/Specialty Organization)_____ for assistance in selecting another physician. The risks of not continuing your medical care include, but are not ... Once my office receives the form, a copy of your records will be transferred within 15 days. Sincerely,

http://www.capphysicians.com/sites/default/files/content/Discontinuing%20a%20Patient%20SAMPLE%20LETTER.doc

Date added: March 1, 2014 - Views: 1

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Documentation Mgmt. Form Template - Montana

Montana Medicaid Youth Psychiatric Residential Treatment Facility Waiver Program Referral Form. Referral Source Information NAME: Date of Referral: Agency: ADDRESS ... PRESCRIBING PHYSICIAN and organization: ... Documentation Mgmt. Form Template Subject: Templates Author: Kate Miller Last ...

http://www.dphhs.mt.gov/mentalhealth/children/documents/PRTFWaiverProgramReferralForm.doc

Date added: December 4, 2012 - Views: 12

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Sample Initial Written Employee Notification Re: Medical ...

has chosen to provide this medical care by using a Workers’ Compensation physician network called a Medical ... as possible. Your employer will provide you with a claim form. ... If appropriate, you may choose a specialist or ask your treating doctor for a referral to a ...

http://www.dir.ca.gov/dwc/MPN/MPN_SampleInitialWrittenEmployeeNotificationLetter.doc

Date added: October 7, 2011 - Views: 76

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FCA Template

FCEConsultants.com * FCE and PR-4 Referral Form . Referral Date: _____ / _____ / _____ Rx: Requesting: ... Referring Physician’s Name: Referring Physician’s Signature: Address: City/State/Zip Code: ... FCA Template ...

http://fceconsultants.averyabramovitch.com/FCE_and_PR4_Referral_Form.doc

Date added: May 10, 2013 - Views: 2

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Documentation Mgmt. Form Template

Montana Medicaid Youth Psychiatric Residential Treatment Facility Waiver Program Referral Form. Referral Source Information NAME: Date of Referral: Agency: ADDRESS ... PRESCRIBING PHYSICIAN and organization ... Documentation Mgmt. Form Template Subject: Templates Author: Kate Miller Last ...

https://montana.fhsc.com/Downloads/Youth/forms/MT_CMHB_DPHHS_Youth_PRTF_Waiver_Program_Referral_Form.doc

Date added: November 24, 2011 - Views: 13

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Format of Dictated Consult Notes: - UT Health Science Center ...

Brief Concluding Statement indicating that the consult was discussed with the attending and thanking the referring physician for the referral. ... Our impressions were (list of diagnoses form highest priority to lowest priority). ...

http://geriatrics.uthscsa.edu/tools/ConsultFormat05.doc

Date added: November 10, 2011 - Views: 8

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Email Template - Washington Association of Diabetes Educators

PHYSICIAN DATA Referral Date:_____ Name: Address: City ... To obtain additional pads of the DIABETES SERVICES AND DIETITIAN REFERRAL form, please call: ... Email Template Author: Mark Hodorowicz Last modified by: Kammer, Ron D Created Date:

http://wadepage.org/files/file/2012%20annual%20conference/DSME_MNT%20Referral.doc

Date added: May 4, 2013 - Views: 7

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OFFICIAL NOTICE - ADE Special Education

Occupational, Physical and Speech Therapy for Medicaid Eligible Beneficiaries. Under Age 21. PRESCRIPTION/REFERRAL. The PCP or attending physician must use this form to prescribe medically necessary Medicaid therapy services or must use this form to make a referral for therapy services.

https://arksped.k12.ar.us/documents/medicaid/DMS_640_08.doc

Date added: October 26, 2012 - Views: 6

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OFFICIAL NOTICE - Arkansas Department of Education

Occupational, Physical and Speech Therapy for Medicaid Eligible Recipients. Under Age 21. PRESCRIPTION/REFERRAL. The PCP or attending physician must use this form to prescribe medically necessary Medicaid therapy services, or must use this form to make a referral for therapy services.

http://arkedu.state.ar.us/commemos/static/fy0203/attachments/Prescription_Referral_Form.doc

Date added: February 7, 2012 - Views: 4

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RESOURSE FOR PHYSICIAN ORDER SHEET - Massachusetts General ...

Put the provider number of the physician in charge of the orders. ... delete “inpatient” from the template for that visit. ... is also a good place to add an order for placement of angiocatheter Please group all blood tubes together for easy referral when checking tubes.

http://www2.massgeneral.org/crc/RESOURCE%20FOR%20PHYSICIAN%20ORDER%20SHEET.doc

Date added: November 2, 2011 - Views: 34

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Articulated Plan Sample Template Instructions

Instructions. The Nurse-Physician Advisory Taskforce for Colorado Healthcare (NPATCH) has created a template to help Advance Practice Nurses create an articulated plan for safe prescribing.

http://www.coloradoafp.org/pdf/Articulated_Plan_Sample_Template.doc

Date added: September 1, 2011 - Views: 30

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Form Instruction and Use - Sequoia Visions

Physician Request Form: ... Treatment bills not supported by ICD-9 codes will be reduced and considered for SIU referral. Supplemental HCFA Form/Instruction: Copy this template onto “HCFA forms” and use the “Supplemental HCFA form template” to place additional ICD-9 codes in cases where ...

http://www.sequoiavisions.com/check/form_use.doc

Date added: July 2, 2012 - Views: 4

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MEDICAL CLEARANCE FORM - Vasectomy Reversal

MEDICAL CLEARANCE FORM. Dear Doctor, We greatly appreciate your attention to this form. Dr. Gatewood can be reached if necessary at 941-756-9110. ... Physician Name: _____ Specialty: _____ Address _____ ...

http://www.vasectomyreversal.net/forms/mc.doc

Date added: September 9, 2011 - Views: 24

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CONTINGENT SEARCH AGREEMENT

The Date of Record is the date the referral is received by XYZ Physician Recruitment. The curriculum vitae and candidate profile must be received by XYZ within 5 working days from the date the referred name is accepted.

http://c.ymcdn.com/sites/www.aspr.org/resource/resmgr/imported/Form-Contingency%20Recruitment%20Agreement%2012-05.doc

Date added: May 3, 2014 - Views: 2

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Check-n-Connect Program

Individualized DPR Template. 40. Section I: Overview & Referral Process. Material. s Summary: ... _____Physician: _____ Additional Medical Concerns: Past Year Information. Office ... the staff will use the Office Discipline Referral Form or the administration will use the Check and Connect ...

http://tier2pbis.pbworks.com/f/Check%20N%E2%80%99%20Connect%20Handbook%20copy.docx

Date added: July 16, 2012 - Views: 8

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COLLABORATIVE PRACTICE AGREEMENT - Texas Tech University ...

Patient referral with physician consult as appropriate. Professional evaluation otherwise delegated by supervising physician. Immediate physician consultation or referral will be made when acute health problems of a complex nature are identified by the PA/ANP.

http://www.ttuhsc.edu/compliance/documents/delegation/Protocol_Alternate_Site.doc

Date added: November 4, 2011 - Views: 30

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NEW PHYSICIAN - ASPR

Physician Preceptor . Checklist Independent Physicians – Checklist. ... Call Duke and Chapel Hill to get their latest referral directories and distribute to new physician(s) Arrange for a sign-on check and promissory note, if applicable.

http://c.ymcdn.com/sites/www.aspr.org/resource/resmgr/imported/Form-New%20Physician%20Orientation%20Checklist.doc

Date added: May 5, 2014 - Views: 2

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CS-1835_Non-FMLA_Medical_Certification_by_Physician

NON-FMLA MEDICAL CERTIFICATION BY PHYSICIAN OR PRACTITIONER. SECTION I ... general nature and duration of treatment, including referral to other provider of health services): Is inpatient ... Questions regarding the use of this template should be referred to Janet Keesler at (517) 335-5584 ...

http://www.michigan.gov/documents/mdcs/CS-1835_Non-FMLA_Medical_Certification_by_Physician_377700_7.doc

Date added: November 7, 2012 - Views: 11

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Progress Note Samples: - California Society of Addiction Medicine

PHYSICIAN/OFFICE INFORMATION. Progress Notes – Sample #1. Patient 1. 8/15/2003. Denies heroin or other illicit drug use. ... Referral to hematologist for evaluation of hep C ## Title: Progress Note Samples: Author: Don Wesson Last modified by: Gail Jara

http://www.csam-asam.org/sites/default/files/pdf/misc/Progress_notes_samples.doc

Date added: January 14, 2012 - Views: 997

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Home Health Care Face-to-Face Encounter Form - PMDA online - Home

Home Health Care Face-to-Face Encounter Form ... I certify that this patient is under my care and that I, or a nurse practitioner or physician’s assistant working with me, had a face-to-face encounter that meets the physician face-to-face encounter requirements with this patient on:

http://www.pamda.org/storage/home%20health%20care%20face-to-face%20encounter%20form.docx

Date added: November 12, 2011 - Views: 55

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SAMPLE DISCHARGE LETTER - Campania

medical society, or physician on-call roster system) to obtain names. of other physicians who may be accepting new patients. Any delay. ... records release authorization form for you to complete and return to. my office as soon as possible. While it is unfortunate that our relationship has ...

http://www.thecampaniagroup.com/lossprevention/Tools/SAMPLE%20DISCHARGE%20LETTER.doc

Date added: November 3, 2011 - Views: 521

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Audiological Services Billing Example: CMS-1500 (audio exc)

The referring physician’s name and NPI number are entered in the Name of Referring Provider or ... (Box 17B) because a written referral from a licensed practitioner is required for ... RP pgs. 3 new template for form (01-05-04) Was audio exh. Renamed audio exc (May 2007) LB ...

http://files.medi-cal.ca.gov/pubsdoco/publications/masters-mtp/part2/audioexc_a02a08.doc

Date added: April 1, 2012 - Views: 4

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PowerPoint Template - National Hospice and Palliative Care ...

The hospice referral process. Explain how patients are referred. ... Hospice election form and any advance directives specific to each patient; Physician certification and recertification of the terminal illness specific to each patient; ...

http://www.nhpco.org/sites/default/files/public/regulatory/NF_edu_toolkit-COC_handout.doc

Date added: May 13, 2013 - Views: 5

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EMPLOYEE MEDICAL CERTIFICATION RELEASE FORM

EMPLOYEE MEDICAL CERTIFICATION RELEASE FORM. ... by a nurse or physician 's assistant under direct supervision of a health care provider, or by a provider of health care services (e.g., physical therapist) under order, of, or on referral by, ...

http://www.pacificu.edu/hr/forms/documents/DR-CERTrelease.DOC

Date added: November 18, 2011 - Views: 200

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stressfreedriverrehab.com

Referral. Date: _____ Name: _____ _____ ___ Date of Birth: _ _____ _ ___ ... Physician’s Address: _____ Phone: _____ Physician’s Signature: _____ Fax ...

http://stressfreedriverrehab.com/form/Template_Medical_Referral.docx

Date added: November 13, 2013 - Views: 1

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Phone Call Log Form - 2secondsetofeyes

Title: Phone Call Log Form Author: Sheree Last modified by: Sheree Created Date: 1/9/2008 7:01:00 PM Company: Expert Solutions, Inc. Other titles: Phone Call Log Form

http://2secondsetofeyes.com/uploads/Phone_Call_Log_Form.doc

Date added: April 6, 2013 - Views: 2561

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BENEFICIARY RECORDS AUDIT - DMEPOS Accreditation provided by ...

Beneficiary Electronic Profile Beneficiary Information Form Emergency Contact Information Referral Information Primary Caregivers Primary Physicians HIPAA Documents Diagnosis Information Physician Orders Home Assessments Goals and Outcomes Certificate of Medical Necessity (CMN ...

http://www.prsrxnetwork.com/instructions/07D-beneficiary_records_audits_template.doc

Date added: May 14, 2013 - Views: 2

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EMPLOYEE: - USDA

WIC Referral form (To WIC from physician) WIC Application (To WIC from anywhere) Public Health Referral form (To other PH areas) ID/VOC Card. Tri-Fold Food Draft Protector. WIC Client Certification form (Turnaround Document) Lab Test Request form(s) – DLS location guide.

http://www.nal.usda.gov/wicworks/Sharing_Center/WI/Nutritionist%20IIOrientationChecklist.doc

Date added: October 15, 2011 - Views: 48

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Documentation Mgmt. Form Template - Montana Behavioral Health ...

ATTENDING PHYSICIAN: IS THE youth IN STATE CUSTODY? Yes No ... If No, does the treatment plan include a referral for an IEP in writing by the parents or legal guardian to the home district? ... Documentation Mgmt. Form Template ...

https://montana.fhsc.com/Downloads/Youth/forms/MT_HCM_Youth_PA_Request_Form_PRTF_or_PRTF_AS-20111109.doc

Date added: May 16, 2012 - Views: 8

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Informed Consent Template - University of Texas at El Paso

The purpose of this template is to assist investigators and other research personnel in creating informed consent documents and to ... please include specific information regarding referral(s) to professional consultation if your project has potential for causing ... In this consent form, ...

http://research.utep.edu/Portals/99/_irb_web/irbnet%20forms/IRB-009%20Informed_Consent_Template%20051409.doc

Date added: November 8, 2012 - Views: 77

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Prescriptions, Referrals, Recommendations and Protocol FAQs

A written referral/recommendation by one of the following is required for IEP assessments: ... In order to rely on another LEA’s physician referral for speech therapy services, ... DHCS Letterhead Template Keywords: Prescriptions,Referrals,Recommendations,Protocol,FAQs

http://www.dhcs.ca.gov/provgovpart/Documents/ACLSS/LEA/FAQs/Prescriptions,%20Referrals,%20Recommendations%20and%20Protocol%20FAQs.docx

Date added: January 2, 2014 - Views: 1

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Screening form for Pharmacist prescribing of antivirals for ...

Any Referral Required? Was the patient referred to a physician or emergency care? Y / N If yes, please ... Screening form template for pharmacists prescribing antivirals under a CDTA 2.

http://www.nwcphp.org/docs/cdta/screening_form_template.doc

Date added: May 29, 2013 - Views: 4

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DRAFT MEMORANDUM OF UNDERSTANDING - Welcome to ADRC Technical ...

Memorandum of Understanding Template. Between. The Area Agency on Aging, Planning and Service Area ____ Aging Resource Center and. The Department of Elder Affairs, ... Send person a: Physician Referral form (3008); Informed Consent (2040); ...

http://www.adrc-tae.acl.gov/tiki-download_file.php?fileId=1914

Date added: February 24, 2013 - Views: 17

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MacPac 8.0 Normal template - HCCA - Health Care Compliance ...

This was promulgated in final form on November 19, 1999. ... Payment of incentives by hospital for each physician referral. 2. Use or provision of free or significantly discounted billing, nursing, ... MacPac 8.0 Normal template ...

http://www.hcca-info.org/Portals/0/PDFs/Resources/library/Case%20Studies%20in%20Recruiting%20and%20Employing%20Physicians.doc

Date added: January 6, 2014 - Views: 1

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This consent form template does not contain HIPAA language

This consent form template contains examples of HIPAA language. ALL consent forms for studies that involve the use or disclosure of protected health information must contain the appropriate HIPAA language, examples of which can be found in their entirety under “Consent Form Templates and Tools ...

http://irb.duhs.duke.edu/wysiwyg/downloads/Consent_Template_-_Long_Form_102_01-02-09_JW.doc

Date added: October 7, 2011 - Views: 12

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REFERRAL MANAGEMENT CENTER - Tricare

INDEX. CHAPTER. PAGE Introduction 4 Referral Management Benefits 5 Referral Management Center (RMC) Roles and Responsibilities 8 MTF and Managed Care Support Contractor (MCSC) Agreements 11 Standardized Referral & Authorization (R&A) Business Rules 12 RMC Staffing Model 15 ...

http://www.tricare.mil/tma/tai/downloads/ref.doc

Date added: August 17, 2011 - Views: 99

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SOCIAL AND BEHAVIORAL SCIENCES APPLICATION FORM

Do not use this form for investigational drug and/or device trials regulated by FDA. ... Self-referral physician-referral public records/database private records/database. Patient medical records Other . Section 8 Care of Subjects in Case of Injury.

http://www.browardhealth.org/upload/docs/irb/newirb/New%20Study%20Social%20Behavioral%20Review%20Template.dot

Date added: September 5, 2013 - Views: 3

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H1N1 Pediatric Office Pandemic Plan Template

Pandemic Influenza Pediatric Office Plan Template: ... Patient Transfer Referral. Supplies/Equipment. Communication . Finances. Legal Considerations. ... Form a “Flu Team” to be in charge of practice decisions related to pandemic and seasonal influenza surge.

http://www.cdc.gov/phpr/healthcare/documents/pediatric_office_plan_template.doc

Date added: September 6, 2012 - Views: 44