ID

19348

Description

Formulare für die vertragsärztliche Versorgung Freigabe durch Dezernat 4 - Ärztliche Leistungen und Versorgungsstruktur Geschäftsbereich Sicherstellung und Versorgungsstruktur Abteilung Sicherstellung Herbert-Lewin-Platz 2 10623 Berlin Tel: + 49 (0) 30 - 4005 -1418 Fax: + 49 (0) 30 - 4005 - 271418 Email: SJohn@KBV.de Web: www.kbv.de Quelle: http://www.kbv.de/html/formulare.php Forms for contract medical care Released by Department 4 - Medical treatment and structure of supply, division ensurance and structure of supply, department ensurance Herbert-Lewin-Platz 2 10623 Berlin Tel: + 49 (0) 30 - 4005 -1418 Fax: + 49 (0) 30 - 4005 - 271418 Email: SJohn@KBV.de Web: www.kbv.de Source: http://www.kbv.de/html/formulare.php

Link

www.kbv.de

Keywords

  1. 12/20/16 12/20/16 -
  2. 9/6/17 9/6/17 -
Copyright Holder

Kassenärztliche Bundesvereinigung

Uploaded on

December 20, 2016

DOI

To request one please log in.

License

Creative Commons BY-NC 3.0

Model comments :

You can comment on the data model here. Via the speech bubbles at the itemgroups and items you can add comments to those specificially.

Itemgroup comments for :

Item comments for :

In order to download data models you must be logged in. Please log in or register for free.

KBV Prescription for visual aid Template 8

KBV Prescription for visual aid; Template 8

Briefkopf
Description

Briefkopf

Name der Krankenversicherung
Description

Health Insurance name

Data type

text

Alias
UMLS CUI [1]
C0021682
Nachname
Description

Patient surname

Data type

text

Alias
UMLS CUI [1]
C0421448
Patientenname
Description

Patient Name

Data type

text

Alias
UMLS CUI [1]
C1299487
Adresse des Patienten
Description

Patient address

Data type

text

Alias
UMLS CUI [1]
C0421449
Patient Geburtsdatum
Description

Patient Birth Date

Data type

date

Alias
UMLS CUI [1]
C0421451
Kostenträgerkennung
Description

Insurance ID

Data type

integer

Alias
UMLS CUI [1]
C1547687
Versichertennummer
Description

Insurance number

Data type

integer

Alias
UMLS CUI [1]
C1549712
Status
Description

Status

Data type

integer

Alias
UMLS CUI [1]
C0449438
Betriebsstättennummer
Description

Facility number

Data type

integer

Alias
UMLS CUI [1]
C1549700
Arzt- Nr.
Description

Physician ID number

Data type

integer

Alias
UMLS CUI [1]
C1548646
Datum
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
IK des Leistungserbringers
Description

Institutional ID

Data type

integer

Alias
UMLS CUI [1,1]
C2607850
UMLS CUI [1,2]
C0600091
Rechnungsnummer
Description

Account number

Data type

text

Alias
UMLS CUI [1]
C1549676
Belegnummer
Description

Billing code

Data type

text

Alias
UMLS CUI [1]
C1547149
Indikation der Verordnung
Description

Indikation der Verordnung

Änderung um mindestens 0,5 Dioptrien
Description

Findings: change of diopters

Data type

boolean

Alias
UMLS CUI [1,1]
C0243095
UMLS CUI [1,2]
C0439484
UMLS CUI [1,3]
C0443172
Befunde:Wird eine Verbesserung der Sehschärfe um mindestens 20% erzielt, falls die Änderung der Dioptrien unter 0,5 liegt?
Description

Findings: improvement of visual acuity

Data type

boolean

Alias
UMLS CUI [1,1]
C0243095
UMLS CUI [1,2]
C0042812
UMLS CUI [1,3]
C2986411
Erstversorgung
Description

Initial supply

Data type

boolean

Alias
UMLS CUI [1,1]
C1279901
UMLS CUI [1,2]
C0419274
Folgeversorgung
Description

Follow up supply

Data type

boolean

Alias
UMLS CUI [1,1]
C0420316
UMLS CUI [1,2]
C1561604
Unfall und Unfallfolgen
Description

Accident and sequelae

Data type

boolean

Alias
UMLS CUI [1,1]
C0000924
UMLS CUI [1,2]
C0243088
Versorgungsleiden
Description

War-injuries, vaccination damage

Data type

boolean

Alias
UMLS CUI [1,1]
C4042938
UMLS CUI [1,2]
C2609236
Sehbehinderung mindestens WHO 1
Description

Vision impairment

Data type

boolean

Alias
UMLS CUI [1]
C1456582
Reparatur
Description

Repair

Data type

boolean

Alias
UMLS CUI [1,1]
C1705181
UMLS CUI [1,2]
C0183277
Ersatz
Description

Replacement

Data type

boolean

Alias
UMLS CUI [1]
C0559956
Menge und Art der Verordnung
Description

Number and type of prescription

Data type

text

Alias
UMLS CUI [1,1]
C1273860
UMLS CUI [1,2]
C0449788
Diagnose/ Begründung
Description

Diagnosis

Data type

text

Alias
UMLS CUI [1]
C0011900
Refraktion
Description

Refraktion

Sphäre rechtes Auge Fernsicht
Description

Sphere right eye distance vision

Data type

integer

Alias
UMLS CUI [1,1]
C0947331
UMLS CUI [1,2]
C0229089
UMLS CUI [1,3]
C0442747
Sphäre linkes Auge Fernsicht
Description

Sphere left eye distance vision

Data type

integer

Alias
UMLS CUI [1,1]
C0947331
UMLS CUI [1,2]
C0229090
UMLS CUI [1,3]
C0442747
Sphäre rechtes Auge Nahsicht
Description

Sphere right eye Near visual acuity

Data type

integer

Alias
UMLS CUI [1,1]
C0947331
UMLS CUI [1,2]
C0229089
UMLS CUI [1,3]
C0429541
Sphäre linkes Auge Nahsicht
Description

Sphere left eye Near visual acuity

Data type

integer

Alias
UMLS CUI [1,1]
C0947331
UMLS CUI [1,2]
C0229090
UMLS CUI [1,3]
C0429541
Zylinder rechtes Auge Fernsicht
Description

Cylinder right eye distance vision

Data type

integer

Alias
UMLS CUI [1,1]
C0946265
UMLS CUI [1,2]
C0229089
UMLS CUI [1,3]
C0442747
Zylinder linkes Auge Fernsicht
Description

Cylinder left eye distance vision

Data type

integer

Alias
UMLS CUI [1,1]
C0946265
UMLS CUI [1,2]
C0229090
UMLS CUI [1,3]
C0442747
Zylinder rechtes Auge Nahsicht
Description

Cylinder right eye Near visual acuity

Data type

integer

Alias
UMLS CUI [1,1]
C0946265
UMLS CUI [1,2]
C0229089
UMLS CUI [1,3]
C0429541
Zylinder linkes Auge Nahsicht
Description

Cylinder left eye Near visual acuity

Data type

integer

Alias
UMLS CUI [1,1]
C0946265
UMLS CUI [1,2]
C0229090
UMLS CUI [1,3]
C0429541
Achse rechtes Auge Fernsicht
Description

Axis right eye distance vision

Data type

integer

Alias
UMLS CUI [1,1]
C0946264
UMLS CUI [1,2]
C0229089
UMLS CUI [1,3]
C0442747
Achse linkes Auge Fernsicht
Description

Axis left eye distance vision

Data type

integer

Alias
UMLS CUI [1,1]
C0946264
UMLS CUI [1,2]
C0229090
UMLS CUI [1,3]
C0442747
Achse rechtes Auge Nahsicht
Description

Axis right eye Near visual acuity

Data type

integer

Alias
UMLS CUI [1,1]
C0946264
UMLS CUI [1,2]
C0229089
UMLS CUI [1,3]
C0429541
Achse linkes Auge Nahsicht
Description

Axis left eye Near visual acuity

Data type

integer

Alias
UMLS CUI [1,1]
C0946264
UMLS CUI [1,2]
C0229090
UMLS CUI [1,3]
C0429541
Prisma rechtes Auge Fernsicht
Description

Prisma right eye distance vision

Data type

integer

Alias
UMLS CUI [1,1]
C1720258
UMLS CUI [1,2]
C0229089
UMLS CUI [1,3]
C0442747
Prisma linkes Auge Fernsicht
Description

Prisma left eye distance vision

Data type

integer

Alias
UMLS CUI [1,1]
C1720258
UMLS CUI [1,2]
C0229090
UMLS CUI [1,3]
C0442747
Prisma rechtes Auge Nahsicht
Description

Prisma right eye Near visual acuity

Data type

integer

Alias
UMLS CUI [1,1]
C1720258
UMLS CUI [1,2]
C0229089
UMLS CUI [1,3]
C0429541
Prisma linkes Auge Nahsicht
Description

Prisma left eye Near visual acuity

Data type

integer

Alias
UMLS CUI [1,1]
C1720258
UMLS CUI [1,2]
C0229090
UMLS CUI [1,3]
C0429541
Basis rechtes Auge Fernsicht
Description

Base right eye distance vision

Data type

integer

Alias
UMLS CUI [1,1]
C0549196
UMLS CUI [1,2]
C0229089
UMLS CUI [1,3]
C0442747
Basis linkes Auge Fernsicht
Description

Base left eye distance vision

Data type

integer

Alias
UMLS CUI [1,1]
C0549196
UMLS CUI [1,2]
C0229090
UMLS CUI [1,3]
C0442747
Basis rechtes Auge Nahsicht
Description

Base right eye Near visual acuity

Data type

integer

Alias
UMLS CUI [1,1]
C0549196
UMLS CUI [1,2]
C0229089
UMLS CUI [1,3]
C0429541
Basis linkes Auge Nahsicht
Description

Base left eye Near visual acuity

Data type

integer

Alias
UMLS CUI [1,1]
C0549196
UMLS CUI [1,2]
C0229090
UMLS CUI [1,3]
C0429541
Scheitelabstand rechtes Auge Fernsicht
Description

Vertex distance right eye distance vision

Data type

integer

Alias
UMLS CUI [1,1]
C0429591
UMLS CUI [1,2]
C0229089
UMLS CUI [1,3]
C0442747
Scheitelabstand linkes Auge Fernsicht
Description

Vertex distance left eye distance vision

Data type

integer

Alias
UMLS CUI [1,1]
C0429591
UMLS CUI [1,2]
C0229090
UMLS CUI [1,3]
C0442747
Scheitelabstand rechtes Auge Nahsicht
Description

Vertex distance right eye Near visual acuity

Data type

integer

Alias
UMLS CUI [1,1]
C0429591
UMLS CUI [1,2]
C0229089
UMLS CUI [1,3]
C0429541
Scheitelabstand linkes Auge Nahsicht
Description

Vertex distance left eye Near visual acuity

Data type

integer

Alias
UMLS CUI [1,1]
C0429591
UMLS CUI [1,2]
C0229090
UMLS CUI [1,3]
C0429541
Rechtes Auge
Description

Right eye

Data type

integer

Measurement units
  • Grad
Alias
UMLS CUI [1]
C0229089
Linkes Auge
Description

Left eye

Data type

integer

Measurement units
  • Grad
Alias
UMLS CUI [1]
C0229090
Kostenrechnung
Description

Kostenrechnung

10-stellige Hilfsmittelpositionsnummer
Description

Medical aid number

Data type

integer

Alias
UMLS CUI [1,1]
C4035891
UMLS CUI [1,2]
C0600091
Betrag in Euro
Description

Sum in Euro

Data type

float

Alias
UMLS CUI [1,1]
C1515051
UMLS CUI [1,2]
C1533125
Rechungsbetrag
Description

Total sum

Data type

float

Alias
UMLS CUI [1,1]
C0439810
UMLS CUI [1,2]
C1533125
Arztstempel /Unterschrift
Description

Signature

Data type

text

Alias
UMLS CUI [1]
C1519316
Erklärung des Versicherten
Description

Erklärung des Versicherten

Ich erkläre, dass ich bisher noch keine Sehhilfe gehabt habe
Description

Statement of first supply

Data type

boolean

Alias
UMLS CUI [1,1]
C1710187
UMLS CUI [1,2]
C1279901
UMLS CUI [1,3]
C0243163
Ich erkläre, dass meine bisherige Sehhilfe verlorengegangen ist
Description

Statement of loss

Data type

boolean

Alias
UMLS CUI [1,1]
C1710187
UMLS CUI [1,2]
C1517945
Datum
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
Unterschrift des Versicherten
Description

signature of insured

Data type

text

Alias
UMLS CUI [1]
C1519316
Entscheidung der Krankenkasse
Description

Entscheidung der Krankenkasse

Die Kosten werden in Höhe des geltenden Festbetrags übernommen
Description

Benefits

Data type

boolean

Alias
UMLS CUI [1]
C0021674
Die Kosten werden in Höhe von... Euro übernommen
Description

Benefits

Data type

float

Alias
UMLS CUI [1]
C0021674
Datum
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
Stempel und Unterschrift der Krankenkasse
Description

Signature

Data type

text

Alias
UMLS CUI [1]
C1519316
Empfangsbestätigung
Description

Empfangsbestätigung

Anzahl Gläser/Kontaktlinsen
Description

Number of vision aids

Data type

integer

Alias
UMLS CUI [1,1]
C0449788
UMLS CUI [1,2]
C0441068
Sonstige Sehhilfen
Description

Other Vision aid

Data type

text

Alias
UMLS CUI [1,1]
C0441068
UMLS CUI [1,2]
C0205394
Datum
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
Unterschrift des Empfängers
Description

Vor und Zuname

Data type

text

Alias
UMLS CUI [1]
C1519316
Bescheinigung des Leistungserbringers
Description

Bescheinigung des Leistungserbringers

Die Sehhilfe wurde gemäß vorstehender Empfangsbestätigung abgegeben und angepasst. Ich versichere, dass die gelieferte Sehhilfe der Verordnung entspricht
Description

Equivalent with prescription

Data type

boolean

Alias
UMLS CUI [1,1]
C0205163
UMLS CUI [1,2]
C0419275
Datum
Description

Date

Data type

date

Alias
UMLS CUI [1]
C0011008
Stempel und Unterschrift des Leistungserbringers
Description

Signature

Data type

text

Alias
UMLS CUI [1]
C1519316

Similar models

KBV Prescription for visual aid; Template 8

Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
Briefkopf
Health Insurance name
Item
Name der Krankenversicherung
text
C0021682 (UMLS CUI [1])
Patient surname
Item
Nachname
text
C0421448 (UMLS CUI [1])
Patient Name
Item
Patientenname
text
C1299487 (UMLS CUI [1])
Patient address
Item
Adresse des Patienten
text
C0421449 (UMLS CUI [1])
Patient Birth Date
Item
Patient Geburtsdatum
date
C0421451 (UMLS CUI [1])
Insurance ID
Item
Kostenträgerkennung
integer
C1547687 (UMLS CUI [1])
Insurance number
Item
Versichertennummer
integer
C1549712 (UMLS CUI [1])
Status
Item
Status
integer
C0449438 (UMLS CUI [1])
Facility number
Item
Betriebsstättennummer
integer
C1549700 (UMLS CUI [1])
Physician ID number
Item
Arzt- Nr.
integer
C1548646 (UMLS CUI [1])
Date
Item
Datum
date
C0011008 (UMLS CUI [1])
Institutional ID
Item
IK des Leistungserbringers
integer
C2607850 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Account number
Item
Rechnungsnummer
text
C1549676 (UMLS CUI [1])
Billing code
Item
Belegnummer
text
C1547149 (UMLS CUI [1])
Item Group
Indikation der Verordnung
Findings: change of diopters
Item
Änderung um mindestens 0,5 Dioptrien
boolean
C0243095 (UMLS CUI [1,1])
C0439484 (UMLS CUI [1,2])
C0443172 (UMLS CUI [1,3])
Findings: improvement of visual acuity
Item
Befunde:Wird eine Verbesserung der Sehschärfe um mindestens 20% erzielt, falls die Änderung der Dioptrien unter 0,5 liegt?
boolean
C0243095 (UMLS CUI [1,1])
C0042812 (UMLS CUI [1,2])
C2986411 (UMLS CUI [1,3])
Initial supply
Item
Erstversorgung
boolean
C1279901 (UMLS CUI [1,1])
C0419274 (UMLS CUI [1,2])
Follow up supply
Item
Folgeversorgung
boolean
C0420316 (UMLS CUI [1,1])
C1561604 (UMLS CUI [1,2])
Accident and sequelae
Item
Unfall und Unfallfolgen
boolean
C0000924 (UMLS CUI [1,1])
C0243088 (UMLS CUI [1,2])
War-injuries, vaccination damage
Item
Versorgungsleiden
boolean
C4042938 (UMLS CUI [1,1])
C2609236 (UMLS CUI [1,2])
Vision impairment
Item
Sehbehinderung mindestens WHO 1
boolean
C1456582 (UMLS CUI [1])
Repair
Item
Reparatur
boolean
C1705181 (UMLS CUI [1,1])
C0183277 (UMLS CUI [1,2])
Replacement
Item
Ersatz
boolean
C0559956 (UMLS CUI [1])
Number and type of prescription
Item
Menge und Art der Verordnung
text
C1273860 (UMLS CUI [1,1])
C0449788 (UMLS CUI [1,2])
Diagnosis
Item
Diagnose/ Begründung
text
C0011900 (UMLS CUI [1])
Item Group
Refraktion
Sphere right eye distance vision
Item
Sphäre rechtes Auge Fernsicht
integer
C0947331 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
C0442747 (UMLS CUI [1,3])
Sphere left eye distance vision
Item
Sphäre linkes Auge Fernsicht
integer
C0947331 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
C0442747 (UMLS CUI [1,3])
Sphere right eye Near visual acuity
Item
Sphäre rechtes Auge Nahsicht
integer
C0947331 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
C0429541 (UMLS CUI [1,3])
Sphere left eye Near visual acuity
Item
Sphäre linkes Auge Nahsicht
integer
C0947331 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
C0429541 (UMLS CUI [1,3])
Cylinder right eye distance vision
Item
Zylinder rechtes Auge Fernsicht
integer
C0946265 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
C0442747 (UMLS CUI [1,3])
Cylinder left eye distance vision
Item
Zylinder linkes Auge Fernsicht
integer
C0946265 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
C0442747 (UMLS CUI [1,3])
Cylinder right eye Near visual acuity
Item
Zylinder rechtes Auge Nahsicht
integer
C0946265 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
C0429541 (UMLS CUI [1,3])
Cylinder left eye Near visual acuity
Item
Zylinder linkes Auge Nahsicht
integer
C0946265 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
C0429541 (UMLS CUI [1,3])
Axis right eye distance vision
Item
Achse rechtes Auge Fernsicht
integer
C0946264 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
C0442747 (UMLS CUI [1,3])
Axis left eye distance vision
Item
Achse linkes Auge Fernsicht
integer
C0946264 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
C0442747 (UMLS CUI [1,3])
Axis right eye Near visual acuity
Item
Achse rechtes Auge Nahsicht
integer
C0946264 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
C0429541 (UMLS CUI [1,3])
Axis left eye Near visual acuity
Item
Achse linkes Auge Nahsicht
integer
C0946264 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
C0429541 (UMLS CUI [1,3])
Prisma right eye distance vision
Item
Prisma rechtes Auge Fernsicht
integer
C1720258 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
C0442747 (UMLS CUI [1,3])
Prisma left eye distance vision
Item
Prisma linkes Auge Fernsicht
integer
C1720258 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
C0442747 (UMLS CUI [1,3])
Prisma right eye Near visual acuity
Item
Prisma rechtes Auge Nahsicht
integer
C1720258 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
C0429541 (UMLS CUI [1,3])
Prisma left eye Near visual acuity
Item
Prisma linkes Auge Nahsicht
integer
C1720258 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
C0429541 (UMLS CUI [1,3])
Base right eye distance vision
Item
Basis rechtes Auge Fernsicht
integer
C0549196 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
C0442747 (UMLS CUI [1,3])
Base left eye distance vision
Item
Basis linkes Auge Fernsicht
integer
C0549196 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
C0442747 (UMLS CUI [1,3])
Base right eye Near visual acuity
Item
Basis rechtes Auge Nahsicht
integer
C0549196 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
C0429541 (UMLS CUI [1,3])
Base left eye Near visual acuity
Item
Basis linkes Auge Nahsicht
integer
C0549196 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
C0429541 (UMLS CUI [1,3])
Vertex distance right eye distance vision
Item
Scheitelabstand rechtes Auge Fernsicht
integer
C0429591 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
C0442747 (UMLS CUI [1,3])
Vertex distance left eye distance vision
Item
Scheitelabstand linkes Auge Fernsicht
integer
C0429591 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
C0442747 (UMLS CUI [1,3])
Vertex distance right eye Near visual acuity
Item
Scheitelabstand rechtes Auge Nahsicht
integer
C0429591 (UMLS CUI [1,1])
C0229089 (UMLS CUI [1,2])
C0429541 (UMLS CUI [1,3])
Vertex distance left eye Near visual acuity
Item
Scheitelabstand linkes Auge Nahsicht
integer
C0429591 (UMLS CUI [1,1])
C0229090 (UMLS CUI [1,2])
C0429541 (UMLS CUI [1,3])
Item
Rechtes Auge
integer
C0229089 (UMLS CUI [1])
Code List
Rechtes Auge
CL Item
0 (1)
CL Item
10 (2)
CL Item
20 (3)
CL Item
30 (4)
CL Item
40 (5)
CL Item
50 (6)
CL Item
60 (7)
CL Item
70 (8)
CL Item
80 (9)
CL Item
90 (10)
CL Item
100 (11)
CL Item
110 (12)
CL Item
120 (13)
CL Item
130 (14)
CL Item
140 (15)
CL Item
150 (16)
CL Item
160 (17)
CL Item
170 (18)
CL Item
180 (19)
Item
Linkes Auge
integer
C0229090 (UMLS CUI [1])
Code List
Linkes Auge
CL Item
0 (1)
CL Item
10 (2)
CL Item
20 (3)
CL Item
30 (4)
CL Item
40 (5)
CL Item
50 (6)
CL Item
60 (7)
CL Item
70 (8)
CL Item
80 (9)
CL Item
90 (10)
CL Item
100 (11)
CL Item
110 (12)
CL Item
120 (13)
CL Item
130 (14)
CL Item
140 (15)
CL Item
150 (16)
CL Item
160 (17)
CL Item
170 (18)
CL Item
180 (19)
Item Group
Kostenrechnung
Medical aid number
Item
10-stellige Hilfsmittelpositionsnummer
integer
C4035891 (UMLS CUI [1,1])
C0600091 (UMLS CUI [1,2])
Sum in Euro
Item
Betrag in Euro
float
C1515051 (UMLS CUI [1,1])
C1533125 (UMLS CUI [1,2])
Total sum
Item
Rechungsbetrag
float
C0439810 (UMLS CUI [1,1])
C1533125 (UMLS CUI [1,2])
Signature
Item
Arztstempel /Unterschrift
text
C1519316 (UMLS CUI [1])
Item Group
Erklärung des Versicherten
Statement of first supply
Item
Ich erkläre, dass ich bisher noch keine Sehhilfe gehabt habe
boolean
C1710187 (UMLS CUI [1,1])
C1279901 (UMLS CUI [1,2])
C0243163 (UMLS CUI [1,3])
Statement of loss
Item
Ich erkläre, dass meine bisherige Sehhilfe verlorengegangen ist
boolean
C1710187 (UMLS CUI [1,1])
C1517945 (UMLS CUI [1,2])
Date
Item
Datum
date
C0011008 (UMLS CUI [1])
signature of insured
Item
Unterschrift des Versicherten
text
C1519316 (UMLS CUI [1])
Item Group
Entscheidung der Krankenkasse
Benefits
Item
Die Kosten werden in Höhe des geltenden Festbetrags übernommen
boolean
C0021674 (UMLS CUI [1])
Benefits
Item
Die Kosten werden in Höhe von... Euro übernommen
float
C0021674 (UMLS CUI [1])
Date
Item
Datum
date
C0011008 (UMLS CUI [1])
Signature
Item
Stempel und Unterschrift der Krankenkasse
text
C1519316 (UMLS CUI [1])
Item Group
Empfangsbestätigung
Number of vision aids
Item
Anzahl Gläser/Kontaktlinsen
integer
C0449788 (UMLS CUI [1,1])
C0441068 (UMLS CUI [1,2])
Other Vision aid
Item
Sonstige Sehhilfen
text
C0441068 (UMLS CUI [1,1])
C0205394 (UMLS CUI [1,2])
Date
Item
Datum
date
C0011008 (UMLS CUI [1])
Signature
Item
Unterschrift des Empfängers
text
C1519316 (UMLS CUI [1])
Item Group
Bescheinigung des Leistungserbringers
Equivalent with prescription
Item
Die Sehhilfe wurde gemäß vorstehender Empfangsbestätigung abgegeben und angepasst. Ich versichere, dass die gelieferte Sehhilfe der Verordnung entspricht
boolean
C0205163 (UMLS CUI [1,1])
C0419275 (UMLS CUI [1,2])
Date
Item
Datum
date
C0011008 (UMLS CUI [1])
Signature
Item
Stempel und Unterschrift des Leistungserbringers
text
C1519316 (UMLS CUI [1])

Please use this form for feedback, questions and suggestions for improvements.

Fields marked with * are required.

Do you need help on how to use the search function? Please watch the corresponding tutorial video for more details and learn how to use the search function most efficiently.

Watch Tutorial