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Surgical Plan Drawing
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Surgical Plan of Procedure
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Surgery Location Checklist
• • •
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Where will procedures be performed
• • •
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Clearance and additional orders
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Clearance Letter Needed
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Clearance letter specifics
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Labs
• • •
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Lab Comments
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Radiology Comments
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Referrals
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Referral Comments
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Education Comments
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General Instructions
• • •
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General Instruction Comments
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Post surgical risks discussed
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Garments
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Garments needed:
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Patient's Measurements:
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Patient will need compression on:
• • •
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Additional orders needed:
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Order date for garments:
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Medical Scribe Present
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Quotes
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Quote 1
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Surgical fee
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Equipment fee
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Total
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Quote 2
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Surgical fee
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Equipment fee
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Total
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Quote 3
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Surgical fee
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Equipment fee
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Total
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Quote 4
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Surgical fee
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Equipment fee
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Total
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Lipedema Letter of Medical Necessity
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Lipedema Letter of Medical Necessity
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To whom it may concern
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Affected areas
• • •
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Remainder of intro
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Surgical Plan
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Re: Patient Name/DOB
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Signature
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Diagnosis Codes
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Hospital Codes
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Hospital Procedure Codes
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Number of units
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Hospital Procedure Codes
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Number of units
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Hospital Procedure Codes
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Number of units
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Hospital Procedure Codes
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Number of units
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Hospital Procedure Codes
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Number of units
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Hospital Procedure Codes
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Number of units
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Hospital Procedure Codes
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Number of units
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ASC Codes
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ASC Procedure Codes
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Number of units
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ASC Procedure Codes
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Number of units
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ASC Procedure Codes
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Number of units
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ASC Procedure Codes
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Number of units
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ASC Procedure Codes
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Number of units
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ASC Procedure Codes
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Number of units
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ASC Procedure Codes
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Number of units
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Office Codes
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Office Procedure Codes
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Number of units
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Office Procedure Codes
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Number of units
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Office Procedure Codes
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Number of units
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Office Procedure Codes
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Number of units
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Office Procedure Codes
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Number of units
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Office Procedure Codes
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Number of units
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Office Procedure Codes
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Number of units
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Office visits
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Number of units
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Number of Stages
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Premera Volume Requirement
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Time to complete
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Where will procedures be performed
• • •
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Signature
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