136.13 - Attachment B - Request to Scan Non-VA Documents ...



Durham VAMCREQUEST TO SCAN NON-VA DOCUMENTS FORMHealth Information Management SectionNOTE: Review “Records to Be Scanned” section and check off any included in this submission. Your signature below shows that clinical review of the documents has been completed and that you request scanning of the attached documents into CPRS. Attach only the documents necessary to be scanned. FROM: (Name of Hospital, Provider, or Doctor where care was provided) _____________________________HEALTH RECORDTo Be Completed By ClinicianPatient Name: ______________________________Social Security #____________________________Date Documents Received: _____ /______ / ______Outside records returned to patient after scanning. ORRecords to be destroyed per preference of the patient after scanning.Records To Be Scanned: Advance DirectiveDischarge Summary History & Physical within 1 yearOperative Reports within 2 yearsProcedure Reports within 2 yearsRadiology Reports within 2 yearPathology Reports within 2 yearOther:MAIL FORM stapled to DOCUMENTS TO BE SCANNED TO: ATTN: File Room/Scanning, FG137Ext. 5322 / 7325 / 7106_________________________________________Print Name and Title_______________________________________________________ _____ / _____ / _____Clinician’s Signature Contact # / Pager # Date Signed by Clinician FOR HIM STAFF USE ONLYQUALITY REVIEW SCANNING CHECKLISTNOTE: HIM employees must complete this section with date performed and initialsRecord Prep Performed ____________ Date/InitialsRecord Returned for clarification ____________ Date/InitialsRecord Scanned ____________ Date/InitialsQuality Review by Scanner ____________ (Concurrent Review) Date/Initials ................
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