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KBV Request for Responsibility of another Health Insurance Template 50

1 Formulär  
Header
Beskrivning

Header

physician name
Beskrivning

physician name

Datatyp

text

Alias
UMLS CUI [1]
C2361125
date of contact
Beskrivning

date of contact

Datatyp

date

Alias
UMLS CUI [1]
C0805839
patient name
Beskrivning

patient name

Datatyp

text

Alias
UMLS CUI [1]
C1299487
Date of birth
Beskrivning

Date of birth

Datatyp

date

Alias
UMLS CUI [1]
C0421451
Patient address
Beskrivning

Patient address

Datatyp

text

Alias
UMLS CUI [1]
C0421449
Insurance number
Beskrivning

Insurance number

Datatyp

integer

Alias
UMLS CUI [1]
C1549712
certificate of incapacity
Beskrivning

certificate of incapacity

Datatyp

boolean

Alias
UMLS CUI [1]
C0869463
prescription
Beskrivning

prescription

Datatyp

text

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

prescription of inpatient treatment

Datatyp

boolean

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

Issue

no membership
Beskrivning

no membership

Datatyp

date

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

to be filled out by physician

correct name and date of birth
Beskrivning

correct name and date of birth

Datatyp

boolean

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

if data incorrect, please correct

Datatyp

text

Alias
UMLS CUI [1]
C1299487
Date of birth
Beskrivning

Date of birth

Datatyp

date

Alias
UMLS CUI [1]
C0421451
insurance id card
Beskrivning

insurance id card

Datatyp

boolean

Alias
UMLS CUI [1]
C3173818
Health Insurance name
Beskrivning

Health Insurance name

Datatyp

text

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

if insurance has been changed, name of new insurance

Datatyp

text

Alias
UMLS CUI [1]
C0021682
EBM
Beskrivning

EBM

treatment date
Beskrivning

treatment date

Datatyp

date

Alias
UMLS CUI [1]
C3173309
Uniform rating scale
Beskrivning

Uniform rating scale

Datatyp

integer

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

Signature

Signature date
Beskrivning

Signature date

Datatyp

date

Alias
UMLS CUI [1]
C0807937
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Similar models

KBV Request for Responsibility of another Health Insurance Template 50

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
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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