FORMS/LETTERS/NARRATIVES WORKSHEET F25 REQUISITION 1836265644

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FORMS/LETTERS/NARRATIVES WORKSHEET

WWW.PAINCAREPHYSICIANS.COM
Patient Name *

First Name Last Name
Patient Date of Birth *

Month Day Year
SMS/Text/Phone of Patient *

Area Code Phone Number
Email of Patient or Representative *
example@example.com
Mailing Address (optional)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Name/Relationship of person filling out form (if different from patient)
DEADLINE (IF ANY). IMPORTANT. We need 15 business days after payment to complete your request.
FAQ: What is the difference between a "Form" and a "Letter"?

Ans: When the client gives us actual documents to fill out that have boxes/lines/etc, that is a "form". When a client says "I need a letter to my insurance, etc", our doctor has to EXPLAIN something from scratch, so that is called a "letter"
PROCESSING FEES NOTICE:

FORMS: Generally, we charge approximately $75.00 for the first 3 pages to process documents such as Disability Forms, FMLA, etc, and then $10.00 per page after the first 2 pages. An example of this is a form that has blanks on it but does not require a separate explanation on a separate page.

LETTERS/NARRATIVES: For narratives and explanations (where our doctor dictates a separate letter to be transcribed explaining your condition), our charges are $250.00 for the first 2 pages of narrative, then $100.00 per page after the first 2 pages.

PAYMENT: We accept check or credit card. To expedite your review, please let us know approximately how many pages you have (for example, 4 pages of forms, or 2 pages of narrative, etc) and the form of payment you expect to utilize so that we may get that invoice out to you in the proper format.

If you have a financial hardship and are unable to pay for these items, please let us know that as well in this section.
OBJECTIVES:

Please provide some information about your goals and objectives with this form, so that we may fill it out properly.
- For example, if you are totally disabled due to an injury, and unable to work at all, and you need help obtaining food stamps, that would be something that we would want to know, as we can incorporate your weight and nutrition into the narrative.
- On the other hand, if you are making a claim against workers compensation, but are having difficulty, then we may want to incorporate the mechanism of injury into our narrative.
- The doctors are looking for much more detail than "I need this for work/insurance etc".
- The greater amount of detail helps us to know a little bit about what a favorable end result looks like for you.
Please enter that information here and feel free to be as detailed as possible.
CLICK all options that would be ACCEPTABLE to you. Do not click any options which would NOT be acceptable if the doctor did not feel it was advisable.
Please click ALL YOUR REQUIREMENTS to complete this task:
What are the objectives of this form/letter/narrative? *
Please provide an answer which is as long and detailed as possible.
REMINDER: Objectives

Please be absolutely clear about your objectives. It will reduce the time and effort required to fill out the form. Feel free to go back and write as much as possible. Patients who receive the fastest service typically write at least 2 full paragraphs in the "Objectives" section so that our doctors fully understand what you require.
CAUSATION:

In your own words, what CAUSED your current medical problems that LED TO THE DISABILITY?

Examples include but are not limited to : Car Accident, Work related injury, Auto-immune issue, or Unknown if you do not know.

Please Respond Here:
Causation
MEDICAL CONDITIONS TO REVIEW:

In your own words, please describe the medical conditions that you would like placed on your form. It is not simply enough to say "see chart", as the person filling out the form may have a number of factors to review.

In this section, please be specific with your body parts (not necessarily your diagnosis). For example, Neck and Arm Pain due to a disc injury; Knee pain despite Knee Replacement; Shoulder dislocation which is inoperable, etc.

For example, if you have a broken hip PLUS have diabetes, kidney failure, and heart congestion, that may be very important for the doctor to write on your form.

Please enter any medical conditions you want placed on your form here :
RELEVANT medical conditions
CURRENT OCCUPATIONAL HISTORY:

Please provide your full work title and occupational role. Are you currently working? If yes, full time/part time/limited? Are you on restrictions (light duty, fewer hours, etc)?

Do you have a job description? If yes, then attach at the end/bottom of this survey before you click "submit"

Please type any relevant information related to your job description here:
Current Occupational
PAST OCCUPATIONAL HISTORY:

Please provide details about prior work history, prior jobs, and missed work which we may need to include in this form/narrative.
Past Occupational HIstory
FUTURE OCCUPATIONAL:

Please provide details of your occupational expectations in the future. Do you believe that you will return to work in a few weeks? A few months? A few years? Never?

Will you return to full duty in same occupation? Light duty? Another occupation?

Please be as specific as possible in your answers here, including timelines:
Future Occupational
PHYSICAL CAPACITY:

Please specify each of the following if impaired, and "none" if not impaired.

Can you lift with your arms and legs? If not, how much is the maximum you can carry?

Do you have fine motor skill loss in hands or feet? Balance?

Limitation of Mental function?

Issues with bending/twisting/or repetitive motion?

Please be as specific as possible. If you leave this section blank we will assume NO DEFECITS in that area.
Physical Capacity
Length of Need: *

Temporary Disability Long Term Disability Permanent Disability

ACTIVITIES OF DAILY LIVING:

Please tell us how your diagnosis has affected your activities of daily living (brushing, combing, walking, exercise, etc).
Type a question
Activities of Daily Living
FUTURE MEDICAL:

Please let us know what treatments you plan to have in the future and when? ie Spine Surgery next month, Knee replacement next year, Nerve Burn next week, etc.
Type a question
Future Medical
SPECIAL HANDLING:

Please provide any special handling instructions here (such as send directly to insurance company, etc). Special Handling Fees may apply
(email, fax, mailing address, etc)
Special Handling
Please attach any forms or files here:

Browse Files

Cancel of

IMPORTANT:

Please be as clear as possible about the objectives of this form. We will compare your chart, and diagnosis. A team of people will be involved with the response.

Acknowledgements

Thank you for submitting the Survey. We will LET YOU KNOW AS SOON AS POSSIBLE IF WE CAN FILL OUT THE FORMS IN A WAY THAT WILL ACHIEVE YOUR GOALS.

Please acknowledge that we will require UPTO 15 business days to process your form, but in most cases the response is much sooner, especially if you have answered all the questions.

Payment is required before processing unless you qualify for financial hardship. We will NOTIFY you of any charges before we proceed with filling out the form.

The process requires a team effort between our doctors, nurses, and medical assistants. While we will make every effort to keep you informed, the best way to expedite a response is to be thorough in answering the questions we have requested on this survey.

Please click SUBMIT when you have completed this survey and your information will automatically be forwarded to an available assistant to begin processing.
Signature of Patient or Authorized Representative *

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FORMS/LETTERS/NARRATIVES WORKSHEET

FAQ: What is the difference between a "Form" and a "Letter"?

REMINDER: Objectives