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Submitted By
Submitted By Email
Priority
--None--
Urgent
High
Medium
Low
Patient Name
Date of Birth:
Visit Type:
--None--
30 EV/OV
30 EVLA
30 RFA
30 RFA/OV
30 V-Seal
30VSeal/OV
45 EV/OV
45 EVLA
45 RFA
45 RFA/OV
45 V-Seal
45VSeal/OV
60 EV/OV
60 EVLA
60 RFA
60 RFA/OV
60 VSeal
60VSeal/OV
ABI
ArterialDx
Auth
Auth/FU
Auth M
Clinic OV
Comp Dress
Consult
COR
COR/US BIL
CVSGovBill
Debridemnt
DVTBILFU
DVTUFU
EV/PHLB/OV
EVLA/PHLEB
F/U Lymph
F/U PHLEB
F/U Wound
FISTULA.SV
FISTULACRT
FISTULAINT
FUAO
FUDV
FUGovBill
FUUSARTB
FUUSARTU
Graft
HmHthCert
I/D
Local Flap
Lymph NP
Minor Proc
MNTBFU
MNTOVCNSLT
MNT OV RR
MNTUFU
MonthlyF/U
NEW PT
OBL ARTINT
OBL BIOPSY
OBLConsult
OBL DV INT
OBL Interv
OBLLabDraw
OBL - OV
OBL PeVD
OBL RR
OBL Screen
OBLScrn GB
OBL UFE
OBL US
OV
OV/AuthM
OV/AuthMFU
OV.AuthM
OV.Mnt.F.U
OV.POAblCh
OV.POABUCH
OVPOPABCH
OVPOPABUCH
OV w/ F/U
PAD Only
PHLEB/OV
Phlebect
PHY/US Bill
PO Abl Chk
POAO
POBUSART
PODV
POUUSART
PR Consult
PRMACTH.EX
PRMACTH.IN
PRMACTH.RV
PROC
PRVS
PVR
PVSGovBill
R/O DVT
R/O DVT EP
R/O DVT NP
RFA/PHB/OV
RFA/PHLB
RO DVT EP
RO DVT NP
RODVTUEP
RODVTUNP
RSEARCH120
RSEARCH60
SCLERO/OV
Screening
Seal/Ph
Seal/Ph/OV
SEGPREP
SEGPRNP
SpiderVein
Stockings
TelVisitWC
TotalUSBil
TtlConCst
U/S-CB
U/S-CB 60m
U/S-CBEP
U/S-CBGB
U/S-CBNP
U/S-CBVSCT
U/S-F/U
U/S GS
UFE
UFE FU
UFE PO
USAO
US Art
USARTABIEP
USARTABINP
USARTBE
USARTBN
US Art Lim
US Art LLE
US Art RLE
USARTSPEP
USARTSPNP
USARTUE
USARTUN
USBilABIEP
USBilABINP
US Bil PAD
USCAROTID
USCBEP
USCBNP
USCUEP
USCUNP
USDeepVein
V.MAPPING
Var/OV
Var UGFS
VS/US Bil
V Screen
VSEGPREP
VSEGPRNP
VSGovBill
Wound Vac
WundBdPrep
WundCareNP
Secondary Case Reason:
--None--
Auth Approved
Auth Denied
Auth expired
Auth Measurement Required
Auth Pending
Clinical Documentation Update Required
Insurance OON
Insurance Terminated
Missing Insurance Info
Missing patient information
Other
PCP Denied Treatment
Physician OON
Pt-Agree w/ PR & Proceed
Pt-Disagree w/ PR & Cancel
Referral Pending
Scheduling Error
Treatment Exclusion in Insurance Plan
Original Appointment Date:
Required Action:
--None--
Additional Information Request
Cancel/Offer Cash Rates
Reschedule
Update/Inform Patient
Earliest Reschedule Date:
Additional Information
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Vein
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Uterine Fibroid
Wound
Results
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