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Patient Intake & History
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Patient Intake & History
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Chief Complaint
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Other
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Subjective
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Impact on Quality of Life
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Conservative Treatments Attempted
• • •
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History of Present Illness
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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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Physical Examination
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Skin
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Other
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Assessment
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Primary Diagnosis
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Medical Necessity Justification
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Keller Scale
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HDSS SCORE
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HIDRO QOL
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Plan
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Treatment Plan
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CPT Codes
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Supporting Documentation
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Patient Attestation
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Follow-up
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Patient Education
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PRIOR AUTHORIZATION REQUEST
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PATIENT HISTORY AND MEDICAL NECESSITY JUSTIFICATON
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CLINICAL SEVERITY ASSESSMENT
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TREATMENT PLAN AND CPT CODES REQUESTED
• • •
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MEDICAL JUSTIFICATION FOR COVERAGE
• • •
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