Review Date(Required) Documenting Therapist:(Required)- Select Therapist -Adam BellNick GunterKim MiddletonElizabeth AllenTina McNealAntonio DeboseDetric GriffinMady LeachPatient Name(Required)Date of Service:(Required) Clinic(Required) Kosciusko Flowood Pearl Reason for Review(Required) Evaluation Not Completed Note Forwarded to PT Patient cancelled / Did not show Note assigned to the wrong therapist Other Use Other if you are requesting individual consideration of circumstances or if your reason for review is not listed above. Please explain your request clearly.Who completed/is responsible for the evaluation?(Required)- Select Therapist -Adam BellNick GunterKim MiddletonElizabeth AllenTina McNealWhich PT was the note forwarded to?(Required)- Select Therapist -Adam BellNick GunterKim MiddletonElizabeth AllenTina McNealHas the patient been marked as Cancelled/No-Show on the schedule?(Required) Yes No Action Required Please update this patient's appointment for the date of service above to Cancelled or No-Show on the schedule. This will prevent the visit from continuing to appear as an outstanding note.Confirmation(Required) I have updated the appointment to Cancelled or No-Show on the schedule. Who should this note be assigned to?(Required)- Select Therapist -Adam BellNick GunterKim MiddletonElizabeth AllenTina McNealAntonio DeboseDetric GriffinMady LeachOther Reason:(Required)Submitted By:(Required)- Select Employee -Adam BellNick GunterKim MiddletonElizabeth AllenTina McNealAntonio DeboseDetric GriffinMady LeachShenita ForestRobbie BreazaeleAdalyn BellSubmitting a Documentation Review Request does not automatically remove an overdue item, approve an exception, or change incentive eligibility. Requests will be reviewed before the final compliance determination whenever reasonably possible.
