2. Affinché flussi d’informazione realizzino azioni efficaci non deve esserci discrepanza Patient Summery

3. Una comunicazione sanitaria è efficace quando raggiunge almeno 3 obiettivi 1.Informa correttamente i cittadini utenti 2.Promuove servizi e risultati utili 3.Crea identità e risposte ai bisogni di salute

4. La forma dà la sostanza e spesso il percepito è più importante del fatto Benedetto Croce

5. Nealth pian Group number Patient insurance ID# Referti!' number (ft applicable) Date referral Issued (if applicable) ReferrIng physician (if applicable) 2. Federal tax ID(TIN) of entity in box 91 1. Name of the Ming provider or facillty 4$ natii appear ah the cne, torei PT DOT a a a a MT Other Both PT and OT ATC DCHome Care MD/DO o New to your office Est'd, new injury Est'd, new episode O Est'd, continuing care o Initial onset (within Iast 3 months) Recurrent (multiple episodes of 3 months) Current Functional Measure Score DASH r (other) Provider Information Nature of Condition Patient Completes This Section: (Please fili in selections completely) DC ONLY Anticipated CMT Level O 98940 O 98942 o 98941 98943 Symptoms began on: 3.Average pain intensity: Last 24 hours: no po i n 28212228 Past week: no pain 1.How often do you experience your symptoms? LO' Constantly (76%-100% of the lime) ® Frequently (51%-75% of the timo) Ci Occasionally (26% - 50% or the time) 1.How much have your symptoms lnterfered with your usual dally activities? (inctuding both work outside the home and housework) C ) Not at all ® A little bit ® Moderately ® Quite a bit 0 Extremely 1.How is your condition changing, since care began at thls facility? e NiA — This is the initial visit O Much worse O Worse A little worse No change A little better 6 O Better 1.In generai, would you say your overall health right now is... C i Exceltent ® Very good O GoodFair ® Poor Patient Signature: X o worst pain t, I Date: ® intermittently(0%-25% or the time) Much better Patient Summary Form PSF-750 (Rev2/18/2009) t =i rei M I Last State Zip code Patient information Patient name Patient address Q Femate O Male I Patient date of birth CIty Instructions Please complete this forni within the specibed timelina and fax to the speuified fax number as indiceied on Plan Summary or plan infor-mation pledously provided 'Fax number mey vary by plan 3.Name and credentia is of the Individuai performIng the service(s) 1.Alternate name (If any) of entlty in box #1 NP1 of entity In box #1 7. Address of the billing provider or facitity indicateci in box *1 8. City 9. State 10. Zip code G. Phone number Provider Com r letes This Section: Date of Surgery Type of Surgery ACL Reconstruction Rotator Culf/Labral Repair Tendon Repair Spinel Fusion Joint Fteplacement Other Diagnosis (ICD codet Please ensure all digita ere entered accuratef y I o Neck Index Back lndexLEFS Indicate where you have pain or other symptoms: Date you want THIS submisslon to begin: l I Patient Type Traumatic Unspectfied Repetitive Post-surgical Work relaled Motor vehicte Cause of Current Episode o l e 2° 4 °

6. Page 2 of 2 Patient Summary Form Nursing Transfer Information: Patient Name: Patient DOB: Height: Weight: Dates requested for dialysis: Current dialysis days: MWF:_____ TuThSat:_____ Other: Hours on dialysis: Access: Other access: Location placed: Date placed: Dry weight: Dialyzer: Reuse: Yes_____ No_____ Heparin Load: Heparin Maintenance: Type: BFR:______ DFR:______ Dialysate: K+______ Ca______ HCO3_____ Drugs: Epogen: Frequency: Other Drugs: Venofer: Frequency: Hectorol: Frequency: Labs: Hepatitis B Ag Date Drawn: Result: Hepatitis B Ab Date Drawn: Result: Complications during dialysis: