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Form preview Texnet enrollment form 00-107 (Rev.1-10/14) Enrollment PAYOR INFORMATION Please type. Payor name PRINT FORM CLEAR FORM 11-digit taxpayer number Mailing address Type of tax or fee payment (i.e. Sales, Franchise, Motor Fuel,
Form preview Bcbs ga fillable eft enrollmen... Electronic Funds Transfer Enrollment Form Electronic Funds Transfer (EFT) Support Atlanta, North Georgia and South Georgia - Please contact your local Representative. Please FAX All Forms to: (404)
Form preview Disenrollment form TRICARE PRIME DISENROLLMENT REQUEST AGENCY DISCLOSURE NOTICE Form Approved OMB No. 0720-0008 Jul 31, 2013 The public reporting burden for this collection of information is estimated to average 5 minutes
Form preview Cigna enrollment change form c... Enrollment / Change Form Consolidated Employer Complete Section A A OPEN ENROLL. CHANGE NEW ENROLL. Insured and/or Administered by Connecticut General Life Insurance Company CIGNA HealthCare Please print and thank you for providing this information EFFECTIVE DATE OF ADD/CHANGE/ CANCELLATION MM/DD/CCYY EMPLOYER NAME EMPLOYER ADDRESS REINSTATE CIGNA ACCOUNT NO. EMPLOYEE S SIGNATURE / DATE 581336c SPOUSE S SIGNATURE / DATE DISTRIBUTION Original CIGN...
Form preview Form inr PATIENT ENROLLMENT FORM FOR PT/INR AT HOME MONITORING SERVICE mdINR - 59 Windsor Hwy Suite 240 New Windsor NY 12553 Quality of Care. Quality of Life Patient Information PATIENT NAME Last Name First Middle Initial DATE OF BIRTH GENDER Male PATIENT MAILING ADDRESS Street Suite Apt and/or Floor HOME PHONE CITY Female EMAIL STATE ZIP CODE EMERGENCY CONTACT Last Name First Middle Initial No Is patient being treated for active infection Yes PHONE If yes please specify below Any known allergies RELATIONSHIP CELL PHONE ORDER TAKEN BY Last Name First Middle Initial TIME DATE Primary Secondary Insurance Information YOU MAY CHOOSE TO FILL IN THE INSURANCE SECTION - OR TO SAVE TIMEYOU MAY FAX A COPY OF BOTH SIDES OF THE PATIENT S INSURANCE CARD OR FAX A SYSTEM PRINT-OUT OF THE PATIENT S INSURANCE INFORMATION PRIMARY INSURANCE NAME OF INSURED if other than the above patient DATE OF BIRTH MAILING ADDRESS Street and or Suite GROUP NUMBER POLICY NUMBER PHONE NUMBER NAME OF EMPLOYER SECONDARY INSURANCE Customer Service Number 800-877-4910 Form 010v4 Enrollment Fax Number 877-222-6580 PHYSICIAN ORDER FORM Ordering Physician Information Patient Name EFFECTIVE DATE PROVIDER NPI PATIENT DATE OF BIRTH PRESCRIBING PHYSICIAN Last Name First Middle Initial PATIENT GENDER GROUP PRACTICE OR HOSPITAL NAME PHYSICIAN OFFICE CONTACT NAME Statement of Medical Necessity and Prescription This patient s condition requires long term anticoagulation therapy to stabilize INR values and reduce the risks associated with thromboembolism such as stroke heart attack and blood clot formation. It is medically necessary for this patient to test his/her INR values frequently to stabilize coagulation and avoid negative outcomes. Enrollment in mdINR s home PT/INR Monitoring Service enables the patient to self-test frequently thereby optimizing therapeutic range. I and my patient understand that results from self-testing will be reported to mdINR for the duration of the patient s anticoagulation therapy. I further certify this patient has been on therapy greater than 90 days and that this patient or his/her caregiver is fully capable of performing these tests reporting the results to mdINR and is able to make adjustments to anticoagulation therapy as directed by me in response to reported results. I understand that mdINR s PT/INR Monitoring Service is for weekly testing patients only. I also understand that all INR results that are 1. 4 and 5. 0 will be considered by mdINR to be Patient Panic Values and I will be notified when results are in this range. Fax Options Patients Diagnosis Atrial Fibrillation / Flutter - 427. 31 Fax Every Result Mechanical Heart Valve - V43. 3 Only Fax Out of Range Results Primary Hypercoagulable State 289. 81 Pulmonary Embolism - 415. 11-415. 19 BELOW ABOVE Fax Out of Range Monthly Summary DVT - 453. 40 NOTE Every result will be faxed unless otherwise specified above. Other Ven* Embolism/ Thrombosis Care Plan TO Target INR Range LOW HIGH mdINR Standard Phone Notification We will call your office for any results 1.

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