SELECT * FROM #Request.prefix_db_agency#.pCMS4857 JOIN #Request.prefix_db_lookup#.pPhysicians ON pPhysicians.Phys_ID = pCMS4857.Render_Phys_ID WHERE Order_ID = '#url.afId#' 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.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 = '#Get485phy.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 * FROM #Request.prefix_db_lookup#.pPhysicians WHERE Emp_ID = '#FORM.Emp_ID#' AND status =0 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, 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.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 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#'
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. Date #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#
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.
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( now(), "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")#
SELECT pCMS4857.Agy_Name, pCMS4857.Agy_CCN,pCMS4857.Agy_Street,pCMS4857.Agy_City, pCMS4857.Agy_State, pCMS4857.Agy_Zip, pCMS4857.Agy_Phone, "" Faxs, "" AS Location,pCMS4857.Pt_Last, pCMS4857.Pt_First ,pCMS4857.Render_Phys_ID AS Primary_ReferringPhys_ID_M0072, pCMS4857.Pt_Agy_ID, pCMS4857.Pt_DOB,pPhysicians.Phys_Last as LastName, pPhysicians.Phys_First as FirstName, pPhysicians.Phys_Street AS Address1,"" AS Address2, pPhysicians.Phys_Street AS City, pPhysicians.Phys_State AS State, pPhysicians.Phys_Zip AS Zip, pPhysicians.Phys_Phone as Telephone1, pPhysicians.Phys_ID ,Order_ID, pCMS4857.Date_Create AS Record_Creation_Date,pCMS4857.Change_by AS Record_Modified_by, "" AS Medical_Num_Item_4, "" AS SOC_Item_2, pCMS4857.Certification_From, pCMS4857.Certification_To,pCMS4857.Date_Sent, Order_description AS Addendum_Details_21, pCMS4857.MD_Digital_Signature, pCMS4857.Date_Received, pCMS4857.Clinician_Signature, 0 AS contact_id,"" AS ContactName,"" AS ContactType,"" AS ContactStreet,"" ContactCity,"" AS ContactState,"" AS ContactZip, pCMS4857.Render_Phys_ID,"" as ContactTelephone1,"" as ContactTelephone2, pPhysicians.Phys_Fax As FAX FROM #Request.prefix_db_agency#.pCMS4857 LEFT OUTER JOIN #Request.prefix_db_lookup#.pPhysicians on pCMS4857.Render_Phys_ID = pPhysicians.Phys_ID WHERE Order_ID = '#url.afid#' Group BY pCMS4857.Order_ID
Medical Update for #Pt_First# #Pt_Last# #Medical_Num_Item_4# DOB: #DateFormat(Pt_DOB,"mm/dd/yyyy")#


Date Order Created: #DateFormat(Record_Creation_Date,"mm/dd/yyyy")#

Agency Assigned Id: #Pt_Agy_ID#

Certification Period: #DateFormat(Certification_From,"mm/dd/yyyy")# to #DateFormat(Certification_To,"mm/dd/yyyy")#

#Agy_Name# #Agy_CCN#
#Agy_Street#
#Agy_City#, #Agy_State# #Agy_Zip#
PHONE #Agy_Phone# FAX #Faxs# #Agy_Name# #Agy_CCN#
#Agy_Street#
#Agy_City#, #Agy_State# #Agy_Zip#
PHONE #Agy_Phone# FAX #Faxs#

_______________________________________________________________
Orders:
#Replace(Addendum_Details_21, CrLf, "
", "ALL")#




_______________________________________________________________
#ContactName#
#ContactStreet#
#ContactCity#, #ContactState# #ContactZip# #ContactTelephone1# #ContactTelephone2# #FirstName# #LastName#
#Address1#
#Address2#
#City#, #State# #Zip#
Tele:#Telephone1# FAX: #FAX#

PHYSICIAN SIGNATURE VALID - Digitally Signed by #Get487.MD_Digital_Signature# Physician Signature_________________________________________ Date __________

#Get487.Clinician_Signature# Staff Signature: Electronically Signed by #GetEmps.Emp_Last#, #GetEmps.Emp_First#       Date #DateFormat( now(), "mm/dd/yyyy")#

// myPdf = fileReadBinary("s3://AKIAIB3P6LHB2BLZDOBQ:dlqosemgbVAzWQpDJvpgVxKRgEd40xFf/B0MVDBU@#Request.bucket_name#/#path#"); request.myPdf = toBase64( gettingfile ); //request.myPdf = toBinary( myPdf ); UPDATE #Request.prefix_db_agency#.pCMS4857 SET Form_Status = 'Sent via Fax', Date_Sent = #now()# WHERE Order_ID = '#url.afid#'