Get Attending Physician's Supplementary Report - Us Department Of ...

This guide provides a detailed overview of how to complete the Attending Physician's Supplementary Report efficiently and accurately online. By following these steps, you can ensure that all necessary information is correctly submitted to facilitate timely processing.

Follow the steps to effectively complete the report online.

1. Click ‘Get Form’ button to access the Attending Physician's Supplementary Report and open it in your chosen application for editing.
2. Begin filling out the form by entering the patient's name in the designated space. Ensure that all information is accurate and clearly written.
3. Indicate the patient's birth date and age in the provided fields. Select the correct gender option using the appropriate radio button.
4. Document the date of completion for the report. This date should reflect when the form is being filled out.
5. State the medical diagnosis related to the patient's hearing condition. This should be specific and clearly articulated.
6. Provide the Medi-Cal ID number, which is essential for patient identification and processing.
7. Enter the date of the ENT examination and specify the location of the exam in the respective areas.
8. Mark the appropriate checkbox(es) indicating whether the hearing loss is in the right ear (AD), left ear (AS), or both ears (AU).
9. Specify when the patient first experienced hearing loss and the circumstances that led to it.
10. Indicate whether the patient has previously worn a hearing aid and the duration for which they have used it.
11. Describe any tinnitus experienced by the patient in the relevant section provided.
12. Document any other physical or mental impairments that may impact the patient’s ability to use a hearing aid.
13. Provide details of any past medical or surgical treatments related to the hearing impairment.
14. Answer whether the patient has any conditions that are medically correctable or that require further evaluation.
15. Indicate the audiological evaluation procedure and name or license of the person who conducted it.
16. Confirm whether a complete examination of the ear, nose, and throat has been performed.
17. Sign the report at the end, and print your name, title, and address below the signature line.
18. Once all fields are filled, review the entire form for accuracy. After confirming all information is correct, you may choose to save changes, download the document, print it, or share it as necessary.

Complete your Attending Physician's Supplementary Report online today to ensure prompt processing.