| Agency Assigned Id |
#GetV.Agency_Assigned_Id# |
| HI Claim Number |
#GetV.HI_Claim_Item_1#
Start of Care #DateFormat(GetV.SOC_Item_2,"mm/dd/yyyy")# |
| Certification Start |
#DateFormat(GetV.Cert_start_Item_3a,"mm/dd/yyyy")#
End #DateFormat(GetV.Cert_End_Item_3b,"mm/dd/yyyy")# |
| Date of Birth |
#DateFormat(GetV.DOB_Item_8,"mm/dd/yyyy")#
Gender #GetV.Gender_Item_9# |
| Medications |
#getV.Active_meds_Item_10# |
| Primary Diagnosis |
#GetV.M0230_ICD_Item_11#
#GetV.M0230_Diagnosis_Item_11#
#DateFormat(GetV.M0230_Date_Item_11,"mm/dd/yyyy")# |
| Surgical Procedure |
#GetV.Surgical_ICD_Item_12#
#GetV.Surgical_Procedure_Item_12#
#DateFormat(GetV.Surgical_Procedure_Date_Item_12,"mm/dd/yyyy")# |
| Diagnosis |
#getV.M0240_ICD_Item_13#
#getV.M0240_Diagnosis_Item_13#
|
| Supplies/DME |
#getV.DME_Supplies_Item_14#
|
| Safety Measures |
#getV.Safety_Measures_Item_15#
|
| Nutrition |
#getV.Nutritional_Item_16#
|
| Allergies |
#getV.Allergies_Item_17#
|
| Functional Limitations |
#getV.Func_Limits_Item_18a#
|
| Other Functional Limits |
#GetV.Func_Limits_Item_18a_other# |
| Activities Permitted |
#getV.Activities_Permitted_Item_18b#
|
| Other Activities Permitted |
#GetV.Activities_Permitted_Item_18b_other# |
| Mental Status |
#getV.Mental_Status_Item_19# |
| Other Mental |
#GetV.Mental_Status_Item_19_other# |
| Prognosis |
#getV.Prognosis_Item_20#
|
| Orders for Care |
#getV.Order_item_21#
|
| Addendum |
#getV.Addendum_Details_21#
|
| Goals Rehab Discharge |
#getV.Goals_Item_22#
|
| DIGITAL SIGNATURE VALID |
Digitally Signed by #GetV.Digital_Signature# #DateFormat(GetV.Date_Received_Item_25,"mm/dd/yyyy")#
|