Medical Information Templates



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Medical Information Templates

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My Medicine Record – FDA

www.fda.gov

Jan 15, 2011 Be an Active Member of Your Health Care Team. My Medicine Record. Name (
Last, First, Middle Initial): www.fda.gov/Drugs/ResourcesForYou/ucm079489.htm.
Birth Date (mm/dd/yyyy): These are my medicines as of. (Enter date as mm/dd/
yyyy): (888) INFO-FDA www.fda.gov/usemedicinesafely.

Responding to Unsolicited Requests for Off-Label Information … – FDA

www.fda.gov

Guidance for Industry. Responding to Unsolicited Requests for. Off-Label
Information About. Prescription Drugs and Medical Devices. DRAFT GUIDANCE.
This guidance document is being distributed for comment purposes only.
Comments and suggestions regarding this draft document should be submitted
within 90 days …

CMS-1500 Template

www.lni.wa.gov

authorizes any entity to release to Medicare medical and nonmedical information,
including employment status, and whether the person has employer group health
insurance, liability, no-fault, worker's compensation or other insurance which is
responsible to pay for the services for which the Medicare claim is made. See 42.

HIPAA Release Form

cityofsanteeca.gov

This medical information may be used by the person I authorize to receive this
information for medical treatment or consultation, billing or claims payment, or
other purposes as I may direct. 5. This authorization shall be in force and effect
until. (date or event), at which time this authorization expires. 6. I understand that I
have …

Summary of Benefits and Coverage Template – CMS.gov

www.cms.gov

Apr 6, 2016 Medical Event. Services You May Need. What You Will Pay. Network Provider. (
You will pay the least). Out-of-Network Provider. (You will pay the most).
Limitations, Exceptions, & Other Important. Information. If you visit a health care
provider's office or clinic. Primary care visit to treat an injury or illness.

living will and durable power of attorney for health care

sos.idaho.gov

concerning artificial life-sustaining care, treatment, services and procedures. You
can also include a statement of your desires concerning other matters relating to
your health care, including a list of one or more persons whom you designate to
be able to receive medical information about you and/or to be allowed to visit you
 …

certificate of medical examination – OPM

www.opm.gov

Privacy Act Statement. Solicitation of this information is authorized by Section
552a of Title 5, United States Code, regarding records maintained on individuals;
Section 3301 of Title 5, United States Code, regarding determination as to an
individual's fitness for employment with regard to age, health, character,
knowledge …

Emergency Action Plan (Template)

www.cdc.gov

Provide the following information: a. Nature of medical emergency, b. Location of
the emergency (address, building, room number), and c. Your name and phone
number from which you are calling. •. Do not move victim unless absolutely
necessary. •. Call the following personnel trained in CPR and First Aid to provide
the.

Certification of Health Care Provider for Employee's Serious Health …

www.dol.gov

medical certification issued by the employee's health care provider. Please
complete Section I before giving this form to your employee. Your response is
voluntary. While you are not required to use this form, you may not ask the
employee to provide more information than allowed under the FMLA regulations,
29 C.F.R. …

Advance Directive – Maryland Attorney General

www.marylandattorneygeneral.gov

If you want information about Do Not Resuscitate (DNR) Orders, please visit the
website http://marylandmolst.org or contact the Maryland. Institute for Emergency
Medical Services Systems directly at (410) 706-. 4367. A Medical Orders for Life-
Sustaining Treatment (MOLST) form contains medical orders regarding …

Advance Directives – State of Michigan

www.michigan.gov

simple and inexpensive or free. This pamphlet contains information on advance
directives … type of medical care you want in the future, or who you want to make
decisions for you, should you lose the ability to … directive provides you some
assurance your personal wishes concerning medical and mental treatment will
be …

Sample Patient Agreement Forms

www.drugabuse.gov

If the medicine is lost or stolen, I understand it will not be replaced until my next
appointment, and may not be replaced at all. I will take my medication as
instructed and not change the way I take it without first talking to the … understand
that I must make sure the office has current contact information in order to reach
me, and.

Life Care Planning Packet – Arizona Attorney General

www.azag.gov

database for the storage of advance directives (Living Will, Medical Power of
Attorney, and Mental Health Power of. Attorney). The Arizona Secretary of State
oversees Registry filings, its security, and its operations. Health care providers
may use the Registry to look up registered directives using the information
provided to …

Make a Budget – Consumer.FTC.gov – Federal Trade Commission

www.consumer.ftc.gov

information to help you plan next month's budget. Some bills are monthly and
some come less often. If you have … Make a Budget. Expenses. Monthly total.
Medicine. $. Health insurance. $. Other health expenses (like doctors'
appointments and eyeglasses). $. Child care. $. Child support. $. Money given or
sent to family. $.

practical advice for drafting and implementing reasonable – EEOC

www.eeoc.gov

E.O. 13164 allows each agency to design procedures that best suit its
organizational needs. However, it requires that the procedures include certain
basic elements, such as the processing of accommodation requests, time limits,
rules for requesting supporting medical information, confidentiality, information
tracking, and.

Guide and Template for Comprehensive Health … – CT.gov

www.ct.gov

Permission to copy, disseminate, or otherwise use information from this Guide is
hereby granted. Appropriate acknowledgement of the source is requested, using
the following citation: Bower, Carol E. 2009. Guide and Template for
Comprehensive Health Improvement Planning,. Version 2.1. Hartford, CT:
Connecticut …

TITLE XIX MEDICAL TRANSPORTATION REIMBURSEMENT FORM …

dss.sd.gov

Name: Date of Birth: Medicaid #:. Address: Phone #:. SECTION 2: PAYMENT
INFORMATION. Payment Goes To: Phone #:. Mailing Address: Have you
completed a NEMT Payment Authorization form? Yes. Your reimbursement will
be deposited after your claim has been processed. Please allow 6-8 weeks for
processing.

Healthcare Coop & Recovery Planning – PHE.gov

www.phe.gov

This document is a collection of resources, ideas, templates and references and
hyperlinks to additional information relating to Healthcare Continuity of
Operations (COOP) and Healthcare. Disaster Recovery. Content for this
document was developed from various resources including government grant
funded publications.