SELECT *,Order_ID, Assmt_ID, Form_Type, Date_Create, Date_sent, Insured_HIC, "" SOC_Item_2, Certification_From, Certification_To, Agy_CCN,Pt_First, Pt_Last, Pt_Street, Pt_City, Pt_State, Pt_Zip, Pt_Phone, Pt_Agy_ID, Agy_Name, Agy_Street, Agy_City, Agy_State, Agy_Zip, Agy_Phone, Agy_NPI, "" Name_Item_6, "" Provider_name_Item_7, Pt_DOB, Pt_Gender, Medications, ICD10, Description, ICD_Date, DME, Safety, Diet,Form_Status, Allergies, Functional_Limits_Extra, Functional_Limitations, Activities_Permitted, Activities_Permitted_Extra, Mental_Status, Mental_Status_Extra, Prognosis, "" AS Order_item_21, "" AS Goals_Item_22, Date_Received, Render_Phys_ID, "" AS Addendum_Details_10, "" AS Addendum_Details_21, "" AS Addendum_Details_22, Change_by, Discharge_Plan, "" AS Digital_Signature, Created_by,Rehabilitation_Potential, Clinician_Signature, MD_Homebound, MD_Clinical_Condition, ""AS CMS_485,record_timestamp, Date_Sent AS Physician_Last_Seen_Date, 0 AS Location FROM #Request.prefix_db_agency#.pCMS4857 WHERE Order_ID = '#url.afId#' ",false,true) /> ",false,true) /> ",false,true) /> ",false,true) /> SELECT pPhysicians.* FROM #Request.prefix_db_lookup#.pPhysicians WHERE Phys_ID = '#Form.Render_Phys_ID#' SELECT Assmt_ID, F179 AS Start_of_Care_M0030, F26 AS Assessment_Reason_M0100, F176 AS Assessment_Completed_M0090, F176 AS Certification_Start, F177 AS Certification_End, "" AS Rehab_Prognosis_M0270, pAdmit.M0030_START_CARE_DT,pAdmit.Date_F2F, pAdmit.clinical_authorization,pAdmit.Clinical_Manager,pAdmit.Case_Manager FROM #Request.prefix_db_agency#.pAssessments JOIN #Request.prefix_db_agency#.pAdmit ON pAdmit.Admit_ID = pAssessments.Admit_ID WHERE Assmt_ID = '#Form.Assmt_ID#' AND pAssessments.status = 0 AND pAdmit.status = 0 ORDER BY F176 Desc SELECT Emp_ID, Emp_First, Emp_Last FROM #Request.prefix_db_lookup#.pEmployee WHERE Emp_ID = '#GetAssessDet.Clinical_Manager#' WHERE Emp_ID = '#GetAssessDet.Case_Manager#' Select Agency_Name, Agency_Address1, Agency_City, Agency_State, Agency_Zip, Natl_Provider_ID, Agency_Contact_Phone, Agency_Fax from #Request.prefix_db_lookup#.Agency where Agency_ID='#session.AgencyID#' SELECT * FROM #Request.prefix_db_agency#.Locations WHERE Location_ID = '#Form.Location#' UPDATE #Request.prefix_db_agency#.pCMS4857 SET Form_Status = 'Printed Only' WHERE Order_ID =


ADDENDUM TO:	PLAN OF TREATMENT	MEDICAL UPDATE

1. Patient's HI claim No.		2. Start Of Care Date		3. Certification Period					4. Medical Record No.		5. Provider No.
#Form.Insured_HIC#		#DateFormat(Form.SOC_Item_2,"mm/dd/yyyy")##DateFormat(GetAssessDet.M0030_START_CARE_DT,"mm/dd/yyyy")#		From:	#DateFormat(Form.Certification_From,"mm/dd/yyyy")##DateFormat(GetAssessDet.Certification_Start,"mm/dd/yyyy")#	To:	#DateFormat(Form.Certification_To,"mm/dd/yyyy")##DateFormat(GetAssessDet.Certification_End,"mm/dd/yyyy")#		#Form.Pt_Agy_ID#		#Form.Agy_CCN#

' & 'telephone ' & #Get_location.Agency_Contact_Phone#&' fax '&#Get_location.Agency_Fax#> ' & 'telephone ' & #Form.Agy_State#> ' & #Form.Agy_Street# & '
' & #Form.Agy_City# & ', ' & #Form.Agy_State# & ' ' & #Form.Agy_Zip# & '
' & #Form.Agy_Phone# & '
'& #Form.Agy_NPI# />

6. Patient's Name and Address	7. Provider's Name, Address and Telephone Number
#Form.Pt_First#, #Form.Pt_Last# #Form.Pt_Street#, #Form.Pt_City#, #Form.Pt_State# #Form.Pt_Zip# #Form.Pt_Phone#	#data#

8. DOB

#DateFormat(Form.Pt_DOB,"mm/dd/yyyy")#

9.Sex

#Form.Pt_Gender#

11. ICD

Principal Diagnosis

Date

#ICD[1]#

#diagnosis[1]#

#DateFormat(primaryICDDate[i],"mm/dd/yy")#
-
-

13. ICD

Other Pertinent Diagnoses

Date

#otherICD[i]#

#otherdiagnosis[i]#

#DateFormat(otherICDDate[i],"mm/dd/yy")#-

10. Medications: Dose/Frequency/Route (N)ew (C)hanged

#Activemeds#

14. DME and Supplies:	15. Safety Measures:
#replace('#Form.DME#',',',', ',"ALL")#	#replace('#Form.Safety#',',',', ',"ALL")#

16. Nutrition:

#replace('#Form.Diet#',',',', ',"ALL")#

17. Allergies:

#Form.Allergies#

18.A. Functional Limitations

#Form.Functional_Limitations#

18.B. Activities Permitted

#Form.Activities_Permitted#

19. Mental Status:

#Form.Mental_Status#

20. Prognosis:

#Form.Prognosis#

22. A Rehabilitation Potential:

#Form.Rehabilitation_Potential#

22.B.Discharge Plans

#Form.Discharge_Plan#

Homebound status:

#Form.MD_Homebound#

Clinical Condition requiring homecare

#Form.MD_Clinical_Condition#

SN Careplans

#Form.Careplan_SN#

SN Goals

#Form.Goals_SN#

PT Careplans

#Form.Careplan_PT#

PT Goals

#Form.Goals_PT#

OT Careplans

#Form.Careplan_OT#

OT Goals

#Form.Goals_OT#

ST Careplans

#Form.Careplan_ST#

ST Goals

#Form.Goals_ST#

MSW Careplans

#Form.Careplan_MSW#

MSW Goals

#Form.Goals_MSW#

HHA Careplans

#Form.Careplan_HHA#

HHA Goals

#Form.Goals_HHA#

23. Signature and Date of Verbal SOC Where Applicable:		25. Date HHA Received Signed POT
#Form.Clinician_Signature#		#DateFormat(Form.Date_Received,"mm/dd/yyyy")#

24. Physician's Name and Address

#Phys_First# #Phys_Last#
#Phys_Street#
#Phys_City#, #Phys_State# #Phys_Zip#
PHONE: #Phys_Phone# FAX: #Phys_Fax# NPI: #Phys_NPI#

26.

I certify/recertify that this patient is confined to his/her home and needs intermittent skilled nursing care, physical therapy and/or speech therapy or continues to need occupational therapy. The patient is under my care, and I have authorized the services on this plan of care and will periodically review the plan.

F2F date : #DateFormat(GetAssessDet.Date_F2F,"mm/dd/yyyy")#

27. Attending Physician's Signature and Date Signed #DateFormat(Form.Physician_Last_Seen_Date,"mm/dd/yyyy")#: Date of physician last face-to-face

DIGITALLY SIGNED BY #Form.Digital_Signature#

28.	Anyone who misrepresents, falsifies, or conceals essential information required for payment of Federal funds may be subject to fine, imprisonment, or civil penalty under applicable Federal laws.


Signature of Physician:		Date

Optional Name/Signature of Nurse/Therapist:		Date
Electronically Signed by #GetEmps.Emp_Last#, #GetEmps.Emp_First#		#DateFormat(Form.Date_Sent, "mm/dd/yyyy")#


Signature of Physician:		Date

Optional Name/Signature of Nurse/Therapist:		Date
Electronically Signed by #GetEmps.Emp_Last#, #GetEmps.Emp_First#		#DateFormat(Form.Date_Sent, "mm/dd/yyyy")#