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THE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. SIGNATURE OF PROVIDER DATE ATPT Form Version 1. ATTENDING PROVIDER TREATMENT PLAN INITIAL SUBMISSION FOLLOW-UP SUBMISSION TYPE OR PRINT LEGIBLY CLAIM PATIENT INFORMATION 1. PATIENT S NAME Last 12. DATE OF ACCIDENT DATE SUBMITTED 13. IS PATIENT S CONDITION RELATED TO 2. PATIENT S ADDRESS No* Street 3. CITY 4. STATE A. EMPLOYMENT 6. TELEPHONE Include Area Code 8. SEX M 9. S*S* NUMBER 20. ZIP CODE NO C. OTHER ACCIDENT Y...
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EMPLOYMENT OR STAY IN L CITATION 20. ZIP CODE Y IS 7. SEX M# — NUMBER Y (Include Area Code) If you wish to obtain more information about your insurance case, please contact, or call. If your case has been forwarded to the insurance department, you will be notified immediately. If the case is pending, please check our website for information about the status of your case. 1. If you were seriously injured and your condition has been stabilized, you should report your injury to an appropriate emergency care provider in the first 24 hours of your injury. The purpose of reporting is to ensure that your condition is evaluated and treated on a timely basis and that you recover as quickly as possible to the normal functioning of your life. 2. If the condition of your injury is unknown, you can contact your medical insurance provider for insurance information or your state Medicaid program for information about the types of health care coverage available to you and information about which hospitals are eligible for coverage. 3. If you have been diagnosed with a serious injury or illness, a medical practitioner may refer you for evaluation by an emergency physician before you are discharged from a hospital. The emergency veterinarian will evaluate you before allowing you to return to your normal, safe job, and may ask you questions about your recent travel and your conditions at home. 4. If your medical care would not endanger you or the public, and are being used to maintain your quality of life, you should consult with a health care provider regarding a waiver or exemption that could improve the quality of the medical treatment provided and allow you to continue working. 1. If your life or health is endangered, you may request a medical emergency waiver from an appropriate medical care provider. In order to request a waiver, you must complete a written request form that shows that you are a victim of domestic violence and are requesting emergency medical care. 2. If you have received an initial medical notice for a domestic violence related injury, you will have until three business days after it is published (that is, before the next business day) to file a claim for compensation or a waiver of the medical notice. 3. If your condition has been stabilized, you can call your insurance claim specialist, your insurance provider or your state Medicaid program directly if you wish to discuss your status for a medical emergency waiver.
PATIENT's PROP INITIAL SUBMISSION FOLLOW-UP SUBMISSION TYPE OR PRINT TO C. EMAIL (SUBMIT IN THE SPOTIFY LOG OR OTHER METHOD) 1. CHAINSAW THREAD (MULTIPLE) 3. CHAINSAW THREAD (CONCUSSION) 6. CHAINSAW THREAD (MULTIPLE) 8. CHAINSAW THREAD (MULTIPLE) 16. CHAINSAW THREAD (CONCUSSION) 19. CHAINSAW THREAD (MULTIPLE) 20. CHAINSAW THREAD (MULTIPLE) 23. CHAINSAW THREAD (MULTIPLE) 26. CHAINSAW THREAD (MULTIPLE) 29.
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