Patient Summary Form PDF Details

In the realm of healthcare, the transparency and accuracy of patient information are vital for effective treatment and administrative processes. The Patient Summary Form PSF-750, revised on July 1, 2015, serves as a comprehensive document that collects essential data on patients, including personal information, insurance details, and health status. It is designed to streamline the communication between patients, healthcare providers, and insurance companies. This form requires patients to provide specific details such as their name, address, date of birth, insurance ID, health plan, and the referring physician's information if applicable. Instructions included with the form guide patients to complete the submission online within a specified timeframe, ensuring that all information is accurately and promptly provided. It also outlines the necessary information about the billing provider or facility, diagnosis codes, and the nature of the patient's condition, among other clinical details. Moreover, the form includes sections for patient-completed data regarding the onset and intensity of symptoms, their impact on daily activities, and the patient's overall health assessment. This structured approach aims to enhance the efficiency of healthcare delivery by ensuring that all parties have access to accurate and current patient information.

QuestionAnswer
Form NamePatient Summary Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesmyoptumhealthphysicalhealth patient summary form, humana patient summary form, patient summary form printable, patient summary form

Form Preview Example

Patient Summary Form

PSF-750 (Rev: 7/1/2015)

Patient Information

 

 

 

 

Female

Patient name

Last

First

MI

Male

 

Patient address

 

 

 

City

Patient insurance ID#

 

 

Health plan

 

Referring physician (if applicable)

 

Date referral issued (if applicable)

Instructions

Please complete this form within the specified timeframe. All PSF submissions should be completed online at www.myoptumhealthphysicalhealth.com unless other- wise instructed.

Please review the Plan Summary for more information.

Patient date of birth

State

Zip code

Group number

Referral number (if applicable)

Provider Information

1. Name of the billing provider or facility (as it will appear on the claim form)

2. Federal tax ID(TIN) of entity in box #1

3.Name and credentials of the individual performing the service(s)

4.Alternate name (if any) of entity in box #1

7.Address of the billing provider or facility indicated in box #1

1 MD/DO 2 DC 3 PT 4 OT 5 Both PT and OT 6 Home Care 7

ATC

8 MT 9 Other

5. NPI of entity in box #1

 

6. Phone number

8. City

9. State

10. Zip code

Provider Completes This Section:

 

 

 

 

 

Date of Surgery

 

Diagnosis (ICD codes)

Date you want THIS

 

 

 

 

 

 

Please ensure all digits are

 

 

 

 

 

 

 

 

 

 

 

 

{1

 

 

 

 

entered accurately

submission to begin:

 

Cause of Current Episode

 

 

 

1°

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

 

 

 

 

 

 

 

 

 

Traumatic

Post-surgical

 

 

 

 

 

 

 

Patient Type

2

Unspecified

45 Work related

TypeACL Reconstructionof Surgery

 

2°

 

 

3

Repetitive

6 Motor vehicle

2

Rotator Cuff/Labral Repair

1

New to your office

 

 

 

 

3

Tendon Repair

 

3°

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

Est’d, new injury

 

 

 

 

4

Spinal Fusion

 

 

 

 

 

3

Est’d, new episode

 

 

 

 

5

Joint Replacement

 

4°

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

Est’d, continuing care

 

 

 

 

6

Other

 

 

 

 

 

 

Nature of Condition

 

 

DC ONLY

 

 

 

 

Current Functional Measure Score

 

 

Anticipated CMT Level

 

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

Initial onset (within last 3 months)

 

 

98940

98942

 

Neck Index

 

 

DASH

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

Recurrent (multiple episodes of < 3 months)

 

 

 

 

 

 

 

 

(other FOM)

3

Chronic (continuous duration > 3 months)

98941

98943

 

Back Index

 

 

LEFS

 

 

 

 

 

 

 

 

 

 

Patient Completes This Section:

 

 

Symptoms began on:

 

 

 

 

 

Indicate where you have pain or other symptoms:

(Please fill in selections completely)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.Briefly describe your symptoms:

2.How did your symptoms start?

3.Average pain intensity:

Last 24 hours:

no pain

0

1

2

3

4

5

6

7

8

9

10

worst pain

Past week:

no pain

0

1

2

3

4

5

6

7

8

9

10

worst pain

4. How often do you experience your symptoms?

1 Constantly (76%-100% of the time) 2 Frequently (51%-75% of the time) 3 Occasionally (26% - 50% of the time) 4 Intermittently (0%-25% of the time)

5. How much have your symptoms interfered with your usual daily activities? (including both work outside the home and housework)

1 Not at all

2 A little bit

3 Moderately

4 Quite a bit

5 Extremely

6. How is your condition changing, since care began at this facility?

0 N/A — This is the initial visit

1 Much worse 2 Worse 3 A little worse 4 No change 5 A little better 6 Better 7 Much better

7. In general, would you say your overall health right now is...

1 Excellent

2 Very good

3 Good

4 Fair

5 Poor

Patient Signature: X

Date:

 

 

 

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1. Fill out your patient summary form pdf with a group of necessary fields. Collect all of the important information and be sure not a single thing neglected!

Writing part 1 of humana patient summary form

2. The next part is to complete the following blank fields: New to your office Estd new injury, Nature of Condition, Spinal Fusion, Joint Replacement, Other, Initial onset within last months, Recurrent multiple episodes of, Chronic continuous duration, Back Index, LEFS, DC ONLY, Anticipated CMT Level, Current Functional Measure Score, Neck Index, and DASH.

humana patient summary form writing process described (stage 2)

3. The next segment is considered quite easy, NA This is the initial visit, Much worse, Worse, A little worse, No change, A little better, Better, Much better, In general would you say your, Excellent, Very good, Good, Fair, Poor, and Patient Signature X - all these empty fields must be filled out here.

Filling in part 3 in humana patient summary form

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