ID

25613

Description

Muster 50 - Anfrage zur Zuständigkeit einer anderen Krankenkasse (Freigabe 04.08.2005). 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 --- Template 50 - Request for Responsibility of another Health Insurance (Released 08-04-2005). 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

Versions (2)
  1. 1/28/17 1/28/17 -
  2. 9/7/17 9/7/17 -
Copyright Holder

KBV

Uploaded on

September 7, 2017

DOI

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License

Creative Commons BY-NC 3.0
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KBV Request for Responsibility of another Health Insurance Template 50

German English

KBV Request for Responsibility of another Health Insurance Template 50

1 forms  
Header
Description

Header

physician name
Description

physician name

Data type

text

Alias
UMLS CUI [1]
C2361125
date of contact
Description

date of contact

Data type

date

Alias
UMLS CUI [1]
C0805839
patient name
Description

patient name

Data type

text

Alias
UMLS CUI [1]
C1299487
Date of birth
Description

Date of birth

Data type

date

Alias
UMLS CUI [1]
C0421451
Patient address
Description

Patient address

Data type

text

Alias
UMLS CUI [1]
C0421449
Insurance number
Description

Insurance number

Data type

integer

Alias
UMLS CUI [1]
C1549712
certificate of incapacity
Description

certificate of incapacity

Data type

boolean

Alias
UMLS CUI [1]
C0869463
prescription
Description

prescription

Data type

text

Alias
UMLS CUI [1]
C0033080
prescription of inpatient treatment
Description

prescription of inpatient treatment

Data type

boolean

Alias
UMLS CUI [1,1]
C0033080
UMLS CUI [1,2]
C0019993
Issue
Description

Issue

no membership
Description

no membership

Data type

date

Alias
UMLS CUI [1,1]
C0021672
UMLS CUI [1,2]
C0680038
UMLS CUI [1,3]
C0011008
to be filled out by physician
Description

to be filled out by physician

correct name and date of birth
Description

correct name and date of birth

Data type

boolean

Alias
UMLS CUI [1]
C1299487
UMLS CUI [2]
C0421451
if data incorrect, please correct
Description

if data incorrect, please correct

Data type

text

Alias
UMLS CUI [1]
C1299487
Date of birth
Description

Date of birth

Data type

date

Alias
UMLS CUI [1]
C0421451
insurance id card
Description

insurance id card

Data type

boolean

Alias
UMLS CUI [1]
C3173818
Health Insurance name
Description

Health Insurance name

Data type

text

Alias
UMLS CUI [1]
C0021682
if insurance has been changed, name of new insurance
Description

if insurance has been changed, name of new insurance

Data type

text

Alias
UMLS CUI [1]
C0021682
EBM
Description

EBM

treatment date
Description

treatment date

Data type

date

Alias
UMLS CUI [1]
C3173309
Uniform rating scale
Description

Uniform rating scale

Data type

integer

Alias
UMLS CUI [1,1]
C0681889
UMLS CUI [1,2]
C0205375
Signature
Description

Signature

Signature date
Description

Signature date

Data type

date

Alias
UMLS CUI [1]
C0807937
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Similar models

KBV Request for Responsibility of another Health Insurance Template 50

1 forms
Name
Type
Description | Question | Decode (Coded Value)
Data type
Alias
Item Group
physician name
Item
text
C2361125 (UMLS CUI [1])
date of contact
Item
date
C0805839 (UMLS CUI [1])
patient name
Item
text
C1299487 (UMLS CUI [1])
Date of birth
Item
date
C0421451 (UMLS CUI [1])
Patient address
Item
text
C0421449 (UMLS CUI [1])
Insurance number
Item
integer
C1549712 (UMLS CUI [1])
certificate of incapacity
Item
boolean
C0869463 (UMLS CUI [1])
prescription
Item
text
C0033080 (UMLS CUI [1])
prescription of inpatient treatment
Item
boolean
C0033080 (UMLS CUI [1,1])
C0019993 (UMLS CUI [1,2])
Item Group
no membership
Item
date
C0021672 (UMLS CUI [1,1])
C0680038 (UMLS CUI [1,2])
C0011008 (UMLS CUI [1,3])
correct name and date of birth
Item
boolean
C1299487 (UMLS CUI [1])
C0421451 (UMLS CUI [2])
if data incorrect, please correct
Item
text
C1299487 (UMLS CUI [1])
Date of birth
Item
date
C0421451 (UMLS CUI [1])
insurance id card
Item
boolean
C3173818 (UMLS CUI [1])
Health Insurance name
Item
text
C0021682 (UMLS CUI [1])
if insurance has been changed, name of new insurance
Item
text
C0021682 (UMLS CUI [1])
Item Group
treatment date
Item
date
C3173309 (UMLS CUI [1])
Uniform rating scale
Item
integer
C0681889 (UMLS CUI [1,1])
C0205375 (UMLS CUI [1,2])
Item Group
Signature
Signature date
Item
Signature date
date
C0807937 (UMLS CUI [1])
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