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TREATMENT CARE PLAN
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Patient insurance
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Comments
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Authorization needed
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Approved authorizations
• • •
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DVT/SVT Comments
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BLOOD THINNER TREATMENT
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Veins To Treat
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LT AK GSV (RFA)
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DATE AND TYPE OF SERVICE
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RT AK GSV (RFA)
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DATE AND TYPE OF SERVICE
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LT SSV (RFA)
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DATE AND TYPE OF SERVICE
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RT SSV (RFA)
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DATE AND TYPE OF SERVICE
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LT AASV (RFA)
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DATE AND TYPE OF SERVICE
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RT AASV (RFA)
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DATE AND TYPE OF SERVICE
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LT PASV (RFA)
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DATE AND TYPE OF SERVICE
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RT PASV (RFA)
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DATE AND TYPE OF SERVICE
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LT BK GSV (Varithena)
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DATE AND TYPE OF SERVICE
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RT BK GSV (Varithena)
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DATE AND TYPE OF SERVICE
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LT ACC #1 (Varithena)
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DATE AND TYPE OF SERVICE
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RT ACC #1 (Varithena)
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DATE AND TYPE OF SERVICE
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LT ACC #2 (Varithena)
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DATE AND TYPE OF SERVICE
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RT ACC #2 (Varithena)
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DATE AND TYPE OF SERVICE
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LT TRIB #1-2 (Sclero)
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DATE AND TYPE OF SERVICE
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RT TRIB #1-2 (Sclero)
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DATE AND TYPE OF SERVICE
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LT TRIB #3-4 (Sclero)
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DATE AND TYPE OF SERVICE
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RT TRIB #3-4 (Sclero)
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DATE AND TYPE OF SERVICE
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LT Perforators
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DATE AND TYPE OF SERVICE
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RT Perforators
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DATE AND TYPE OF SERVICE
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