Get Camp Lejeune Family Member Program Treatingphysicians Report - 10-10068b The Treating Physician

Filling out the Camp Lejeune Family Member Program Treating Physician Report is an essential step in the eligibility determination process for individuals affected by contaminated water exposure. This guide provides clear and comprehensive instructions to help physicians accurately complete the form online.

Follow the steps to successfully complete the report.

1. Click the ‘Get Form’ button to obtain the form and open it in your online editor.
2. Enter the patient's personal information, including their name, date of birth (MMDDYYYY), and social security number. Ensure that all details are accurate.
3. Review the history of specific conditions or illnesses related to the patient's exposure at Camp Lejeune. Select 'Yes' or 'No' to indicate the presence of any relevant conditions. If 'Yes' is selected, check all applicable conditions listed, such as bladder cancer, lung cancer, or any other indicated condition. Include additional information for conditions requiring it.
4. Provide the specific diagnosis for the patient, including relevant ICD-9/10 code(s) and the date of diagnosis.
5. Indicate the date of the patient's most recent visit for the diagnosed condition, along with the current status of the condition (active, remission, or other).
6. Detail the treatment provided to the patient, including the start dates for radiation, chemotherapy, and surgery. Also, include anticipated end dates for ongoing treatments.
7. Complete the narrative section by listing any co-morbidities, risk factors, or other exposures that may have influenced the diagnosed condition.
8. Physicians should assess and document symptoms, diagnostic tests, or any additional relevant information for specific conditions such as hepatic steatosis, renal toxicity, and neurobehavioral effects.
9. Finally, sign and date the report to certify the information provided is true. Include the physician's name, tax ID number, contact information, and national provider identifier (NPI).
10. Once all sections are completed, review the form for accuracy. Users can save changes, download, print, or share the completed report as needed.

Complete the Camp Lejeune Family Member Program Treating Physician Report online today to assist in determining eligibility.