Get Textbook Of Military Medicine. Part 3. Disease And The ... - Dtic

Filling out the Textbook Of Military Medicine. Part 3. Disease And The ... - DTIC can seem daunting, but with this step-by-step guide, you will be equipped with the knowledge to complete the document accurately and efficiently. This guide is designed to help users at all levels navigate the form and understand its various sections.

Follow the steps to accurately complete the form.

1. Click the ‘Get Form’ button to obtain the form and open it in the appropriate environment for editing.
2. Begin by entering an 'X' in the appropriate box for the Coverage Indicator area, which signifies insurance details.
3. In the Insured's ID Number field, input the patient's nine-digit Medical Assistance identification number.
4. Enter the patient's name in the Patient's Name field. Ensure it is spelled exactly as it appears on the Medical Assistance ID card.
5. For the Patient's Birthdate/Sex section, provide the date of birth in MMDDYY format followed by the patient's sex.
6. Fill in the Patient's Address with detailed information: street, city, state, and zip code.
7. For the Insurance Plan Name, document the three-digit carrier code along with the name of any additional insurance the patient has.
8. Identify if the condition is related to employment or an accident in the Condition Related section. Mark the appropriate boxes and provide relevant state codes if necessary.
9. Indicate if there is any other health benefit plan by checking ‘Yes’ or ‘No’ at the designated field.
10. In the Patient's or Authorized Person's Signature section, enter the patient's signature or write 'Signature on File.' Ensure this signature is kept on file by the provider.
11. Complete the Referring Physician sections (17 to 17b) by entering the necessary details of the physician who referred the patient.
12. Document any hospitalization dates in the related section using MMDDYY format.
13. For the Outside Lab field, specify whether lab work was processed externally by checking the corresponding box.
14. Provide up to four ICD-9-CM diagnosis codes that relate to the patient's treatment in the Diagnosis section.
15. In the Date(s) of Service section, enter the service dates in the specified MMDDYY format.
16. Fill in the Place of Service using appropriate codes based on where the service took place.
17. Document the Emergency Indicator as 'Y' if emergency services were rendered.
18. In the Procedure Code section, input the HCPCS code(s) that describe the services performed and any applicable modifications.
19. Reference the diagnosis codes corresponding to each procedure in the Diagnosis Code area.
20. Log the charges for each procedure in the Charges section.
21. Indicate the number of days or units rendered for services in the Days or Units field.
22. Fill out the EPSDT/Family Planning section appropriately based on the nature of the services provided.
23. Complete the billing provider sections, including the necessary qualifications and identifiers.
24. Finally, review the entire form for accuracy and completeness before saving changes, downloading, printing, or sharing the document as needed.

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