Documentation Requests

Edit

First Name

Last Name

Address

Address 2

City

State

Zip

Contact Information

Email

Primary

Phone

Type

Primary

Preferences

Language

Primary

Translator Needed?

Yes No

Care Team

Name

Relationship

Email

Primary

Phone

Type

Primary

First Name

Last Name

Address

Address 2

City

State

Zip

Contact Information

Email

Set as Primary

Primary

Secondary Email

Set as Primary

Phone

Type

Preferences

Language

Set as Primary

Primary

Translator Needed?

Yes No

Set as Primary

Care Team

Name

Relationship

Email

Set as Primary

Primary

Secondary Email

Set as Primary

Phone

Type

Primary Care Provider

PCP Name: Dr. Dave Eustis
Location Name: Accretive Clinic
Physician Specialty: Family Medicine
Physician Credential: MD
Most Recent Service Date: 03/15/2015
Most Recent Visit Reason: Wellness Visit
System: Ford
Physician Phone: (999) 999-9999

Specialist

PCP Name: Dr. Mikah Trent
Location Name: Accretive Clinic
Physician Specialty: Internal Medicine
Physician Credential: MD
Most Recent Service Date: 03/15/2014
Most Recent Visit Reason: Flu Shot
System: Ford
Physician Phone: (999) 999-9999

Set as PCP

Specialist

PCP Name: Dr. Jeffrey Anscomb
Location Name: McFadden Medical
Physician Specialty: Cardiology
Physician Credential: MD
Most Recent Service Date: 03/15/2015
Most Recent Visit Reason: Echocardiogram
System: Ford
Physician Phone: (999) 999-9999

Set as PCP

Specialist

PCP Name: Dr. Daniel Dooley
Location Name: Michigan Medical
Physician Specialty: Podiatry
Physician Credential: MD
Most Recent Service Date: 04/16/2015
Most Recent Visit Reason: Diabetic Screening
System: Ford
Physician Phone: (999) 999-9999

Set as PCP

Action	whiteNumberBox	Note	Activity	Call User
No answer, left message with person	04/27/2015 - 9:02 AM	Jonathan was not home. A message was left with his sister.	Patient Engagement	Susan Peterson
Busy Signal	04/25/2015 - 10:23 AM	N/A	Documentation & Coding	Susan Peterson
Left Voicemail	04/21/2015 - 11:05 AM	No answer. Left message.	Patient Engagement	Jared Allen
Guarantor Requests Call Back	03/27/2015 - 3:02 PM	Spoke with Jonathan, however something came up and the call needed to be disconnected	Patient Engagement	Susan Peterson
No answer, left message with person	04/27/2015 - 9:02 AM	Jonathan was not home. A message was left with his sister.	Documentation & Coding	Susan Peterson
No answer, left message with person	04/27/2015 - 9:02 AM	Jonathan was not home. A message was left with his sister.	Patient Engagement	Susan Peterson
No answer, left message with person	04/27/2015 - 9:02 AM	Jonathan was not home. A message was left with his sister.	Patient Engagement	Susan Peterson
No answer, left message with person	04/27/2015 - 9:02 AM	Jonathan was not home. A message was left with his sister.	Patient Engagement	Susan Peterson
Busy Signal	04/25/2015 - 10:23 AM	N/A	Documentation & Coding	Susan Peterson
Left Voicemail	04/21/2015 - 11:05 AM	No answer. Left message.	Patient Engagement	Jared Allen
Guarantor Requests Call Back	03/27/2015 - 3:02 PM	Spoke with Jonathan, however something came up and the call needed to be disconnected	Patient Engagement	Susan Peterson
No answer, left message with person	04/27/2015 - 9:02 AM	Jonathan was not home. A message was left with his sister.	Documentation & Coding	Susan Peterson
No answer, left message with person	04/27/2015 - 9:02 AM	Jonathan was not home. A message was left with his sister.	Patient Engagement	Susan Peterson
No answer, left message with person	04/27/2015 - 9:02 AM	Jonathan was not home. A message was left with his sister.	Patient Engagement	Susan Peterson

Clinic / Department	Physician	Reason	Date	Time	Date Scheduled
Quest Diagnostics	—	Mammogram	04/15/2015	9:00 AM	03/10/2015
St. Michael's Medical	Dr. Smith	Wellness	02/10/2015	11:00 AM	01/15/2015