Form Pt Inr PDF Details

Navigating the complexities of healthcare, the PT/INR form emerges as a crucial tool for patients requiring anticoagulation therapy, facilitating their enrollment in home monitoring services. Located at 59 Windsor Hwy, Suite 240, New Windsor, NY, mdINR emphasizes the enhancement of both care quality and life quality through this form. The document gathers comprehensive patient information, including name, address, allergies, and the presence of any active infections, underscoring the personalized approach to each patient's care. Moreover, it details insurance information meticulously, allowing for a streamlined process in securing coverage for the service. The form extends to capture the prescribing physician's details, reinforcing the collaborative care model between the patient, healthcare providers, and mdINR. A significant section is dedicated to the Statement of Medical Necessity and Prescription, which underscores the critical nature of regular INR tests for patients on warfarin therapy, to prevent the risks associated with irregular blood coagulation levels. It specifies the patient’s diagnosis, setting forth a care plan that includes the target INR range and test frequency, ensuring precise monitoring. This document not only represents an administrative requirement but also a gateway to safer, more efficient patient care in the landscape of anticoagulation management.

QuestionAnswer
Form NameForm Pt Inr
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform inr pdf, mdinr enrollment form, form enrollment inr, mdinr form

Form Preview Example

PATIENT ENROLLMENT FORM

FOR PT/INR AT HOME MONITORING SERVICE

mdINR - 59 Windsor Hwy, Suite 240, New Windsor, NY 12553Quality of Care. Quality of Life

Patient Information

PATIENT NAME: (Last Name, First, Middle Initial)

 

DATE OF BIRTH:

GENDER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

Fem ale

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PATIENT MAILING ADDRESS: (Street, Suite, Apt, and/or Floor)

HOME PHONE:

CELL PHONE:

 

 

 

 

 

 

 

 

 

 

CITY:

STATE:

ZIP CODE:

EMAIL:

 

 

 

 

 

 

 

 

 

 

 

 

EMERGENCY CONTACT: (Last Name, First, Middle Initial)

RELATIONSHIP:

PHONE:

 

 

 

 

 

 

 

 

 

 

Any known allergies?

If yes, please specify below:

Yes

No

Is patient being treated for active infection?

If yes, please specify below:

Yes

No

ORDER TAKEN BY: (Last Name, First, Middle Initial)

DATE:

TIME:

Primary & Secondary Insurance Information

YOU MAY CHOOSE TO FILL IN THE INSURANCE SECTION

- OR TO SAVE TIME-

YOU MAY FAX A COPY OF BOTH SIDES OF THE PATIENT'S INSURANCE CARD, OR

FAX A SYSTEM PRINT-OUT OF THE PATIENT'S INSURANCE INFORMATION

PRIMARY INSURANCE:

NAME OF INSURED: (if other than the above patient)

DATE OF BIRTH:

MAILING ADDRESS: (Street, and or Suite)

GROUP NUMBER:

CITY:

STATE:

ZIP CODE:

POLICY NUMBER:

PHONE NUMBER:

NAME OF EMPLOYER:

SECONDARY INSURANCE:

NAME OF INSURED: (if other than the above patient)

DATE OF BIRTH:

MAILING ADDRESS: (Street, and or Suite)

GROUP NUMBER:

CITY:

STATE:

ZIP CODE:

POLICY NUMBER:

PHONE NUMBER:

NAME OF EMPLOYER:

Customer Service Number: 800-877-4910

Enrollment Fax Number: 877-222-6580

Form # 010v4

PHYSICIAN ORDER FORM

FOR PT/INR AT HOME MONITORING SERVICE

mdINR - 59 Windsor Hwy, Suite 240, New Windsor, NY 12553

Quality of Care. Quality of Life

Ordering Physician Information & Patient Name

EFFECTIVE DATE:

PROVIDER NPI:

PATIENT NAME: (Last Name, First, Middle Initial)

 

PRESCRIBING PHYSICIAN: (Last Name, First, Middle Initial)

PATIENT DATE OF BIRTH:

PATIENT GENDER:

 

 

 

Male

Fem ale

GROUP PRACTICE OR HOSPITAL NAME:

 

PHYSICIAN OFFICE CONTACT NAME:

 

 

 

 

 

MAILING ADDRESS (Street, and/or Suite)

 

PHYSICIAN OFFICE PHONE:

PHYSICIAN OFFICE FAX:

 

 

 

 

 

CITY:

STATE:

ZIP CODE:

PHYSICIAN OFFICE EMAIL:

 

 

 

 

 

 

Any known allergies?

If yes, please specify below:

Yes

No

Is patient being treated for active infection?

If yes, please specify below:

Yes

No

Statement of Medical Necessity and Prescription

This patient's condition requires long term anticoagulation therapy to stabilize INR values and reduce the risks associated with thromboembolism such as stroke, heart attack, and blood clot formation. It is medically necessary for this patient to test his/her INR values frequently to stabilize coagulation and avoid negative outcomes. Enrollment in mdINR's home PT/INR Monitoring Service enables the patient to self-test frequently thereby optimizing therapeutic range. I, and my patient, understand that results from self-testing will be reported to mdINR for the duration of the patient's anticoagulation therapy.

I further certify this patient has been on warfarin therapy greater than 90 days and that this patient (or his/her caregiver) is fully capable of performing these tests, reporting the results to mdINR, and is able to make adjustments to anticoagulation therapy as directed by me in response to reported results.

I understand that mdINR's PT/INR Monitoring Service is for weekly testing patients only. I also understand that all INR results that are ≤ 1.4 and ≥ 5.0 will be considered by mdINR to be Patient Panic Values and I will be notified when results are in this range.

Patients Diagnosis

At rial Fibrillat ion / Flut t er - 427.31

Mechanical Heart Valve - V43.3

DVT - 453.40

Prim ary Hypercoagulable St at e 289.81

Pulm onary Em bolism - 415.11-415.19

Ot her Ven. Em bolism / Throm bosis

Fax Options

Fax Every Result

 

 

 

Only Fax Out of Range Result s

BELOW:

 

ABOVE:

Fax Out of Range + Mont hly Sum m ary

BELOW:

 

ABOVE:

NOTE: Every result w ill be faxed unless ot herw ise specified above.

Care Plan

Target INR Range:

TO

Test Frequency: Weekly

LOW

HIGH

mdINR Standard Phone Notification:

 

 

Training by:

 

m dINR Trainer

Physician Office

 

 

 

 

 

 

 

We will call your office for any results ≤ 1.4 OR ≥ 5.0

NOTE: Training w ill be perform ed by an m dINR Trainer if not select ed above

 

 

 

 

 

 

 

 

Ot her phone not ificat ion range: Below:

Above:

Medication:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No phone not ificat ion - fax only.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PHYSICIAN SIGNATURE:

DATE:

1234567890

Customer Service Number: 800-877-4910

Enrollment Fax Number: 877-222-6580

Form # 010v4

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To be able to fill out this PDF document, be sure you provide the necessary information in each blank:

1. It is crucial to complete the form patient enrollment inr correctly, hence pay close attention when working with the areas that contain these specific fields:

Filling in section 1 of form inr monitoring

2. Just after this array of blanks is done, go to enter the applicable information in all these: PRIMARY INSURANCE, NAME OF INSURED if other than the, DATE OF BIRTH, MAILING ADDRESS Street and or Suite, GROUP NUMBER, CITY, STATE, ZIP CODE, POLICY NUMBER, PHONE NUMBER, NAME OF EMPLOYER, SECONDARY INSURANCE, NAME OF INSURED if other than the, DATE OF BIRTH, and MAILING ADDRESS Street and or Suite.

How one can fill in form inr monitoring step 2

3. This next step is considered quite straightforward, Customer Service Number, Enrollment Fax Number, and Form v - all these blanks will need to be completed here.

Writing part 3 in form inr monitoring

4. Completing EFFECTIVE DATE, PROVIDER NPI, PATIENT NAME Last Name First, PRESCRIBING PHYSICIAN Last Name, PATIENT DATE OF BIRTH, PATIENT GENDER, Male, Female, GROUP PRACTICE OR HOSPITAL NAME, PHYSICIAN OFFICE CONTACT NAME, MAILING ADDRESS Street andor Suite, PHYSICIAN OFFICE PHONE, PHYSICIAN OFFICE FAX, CITY, and STATE is crucial in this form section - always don't hurry and fill in every single field!

The right way to fill in form inr monitoring portion 4

5. This document needs to be completed with this particular segment. Here you can see a comprehensive listing of form fields that need correct information in order for your document usage to be complete: I further certify this patient has, Fax Options, Atrial Fibrillation Flutter, Mechanical Heart Valve V, DVT, Primary Hypercoagulable State, Pulmonary Embolism, Other Ven Embolism Thrombosis, Fax Every Result, Only Fax Out of Range Results, BELOW, Fax Out of Range Monthly Summary, BELOW, NOTE Every result w ill be faxed, and Care Plan.

Atrial Fibrillation Flutter, Mechanical Heart Valve V, and BELOW in form inr monitoring

You can potentially make an error while filling out the Atrial Fibrillation Flutter, for that reason make sure you look again prior to deciding to finalize the form.

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