Instructions:
(If possible try to use the same pending status such as "no response" or "review with spouse" etc for all 20 entries)Please use the "tab" button ONLY when moving to the next box.Pressing the "enter" button will automatically save the form. A new window will open with a link to access your form for editing or completing. An email with the same link will also be sent.To submit your completed form the "submit" button must be pressed located at the bottom of this form.* Required information
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Total/Average
Pending Exam: First name, initials or number onlyExam Date: Initial exam dateFirst Follow Up Date: This is the date of the initial follow up action after the examMethod Of Follow Up: Phone Call, Text, Email or Left VoicemailLast Follow Up Date: This is the date of the last follow up action takenMethod Of Follow Up: Phone Call, Text, Email or Left VoicemailTreatment Fee: The total amount of the recommended treatment plan# Of Days From The Exam To The First Follow Up Action# Of Days From The Exam To The Last Follow Up ActionOverall Aging: # of days from the exam date to the date this form is being completed