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Patient Intake & History
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Patient Intake & History
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Patient Intake & History
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Patient Intake & History
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Subjective
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Chief Complaint
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Other
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History of Present Illness
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Other
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Conservative Treatments Attempted
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Other
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Objective Findings
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Image 1
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Image 2
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Image 3
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Image 4
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General
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Other
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Skin
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Vital Signs
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Assessment
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Primary Diagnosis
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Medical Necessity Justification
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Impact on Quality of Life
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Other
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Plan
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Treatment
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CPT Codes
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Other
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Supporting Documentation
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Follow-up
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Patient Education
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Other
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Social History
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Past Medical HX
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Allergies
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Patient denies
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CONSTITUTIONAL SYMPTOMS
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REVIEW OF SYSTEMS/ SUBJECTIVE DATA
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If Other, specify and describe
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Illicit Drug Use
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Drug Allergies
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Family HX
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