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| The types of information that were requested or received on this Additional Information Contact. |
| May contain organization-specific values: Yes |
| Category Entries: |
| Report Justifying Treatment Beyond Utilization Guidelines |
| Drugs Administered |
| Treatment Diagnosis |
| Initial Assessment |
| Functional Goals |
| Plan of Treatment |
| Progress Report |
| Continued Treatment |
| Chemical Analysis |
| Certified Test Report |
| Justification for Admission |
| Recovery Plan |
| Social Security Benefit Letter |
| Rental Agreement |
| Benefit Letter |
| Support Data for Verification |
| Allergies/Sensitivities Document |
| Autopsy Report |
| Ambulance Certification |
| Admission Summary |
| Purchase Order Attachment |
| Prescription |
| Physician Order |
| Benchmark Testing Results |
| Baseline |
| Blanket Test Results |
| Chiropractic Justification |
| Consent Form(s) |
| Drug Profile Document |
| Dental Models |
| Durable Medical Equipment Prescription |
| Diagnostic Report |
| Discharge Monitoring Report |
| Discharge Summary |
| Family Medical History Document |
| Health Certificate |
| Health Clinic Records |
| Immunization Record |
| State School Immunization Records |
| Laboratory Results |
| Medical Record Attachment |
| Nursing Notes |
| Operative Note |
| Oxygen Content Averaging Report |
| Orders and Treatments Document |
| Objective Physical Examination (including vital signs) Document |
| Oxygen Therapy Certification |
| Pathology Report |
| Patient Medical History Document |
| Periodontal Charts |
| Periodontal Reports |
| Parenteral or Enteral Certification |
| Physical Therapy Notes |
| Prosthetics or Orthotic Certification |
| Paramedical Results |
| Physician’s Report |
| Physical Therapy Certification |
| Cause and Corrective Action Report |
| Quality Report |
| Radiology Films |
| Radiology Reports |
| Report of Tests and Analysis Report |
| Renewable Oxygen Content Averaging Report |
| Symptoms Document |
| Death Notification |
| Photographs |