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KBV Cost Coverage Application form Template 56

1 Formulär  
Header
Beskrivning

Header

Health Insurance name
Beskrivning

Health Insurance name

Datatyp

text

Alias
UMLS CUI [1]
C0021682
Patient surname
Beskrivning

Patient surname

Datatyp

text

Alias
UMLS CUI [1]
C0421448
Patient Name
Beskrivning

Patient Name

Datatyp

text

Alias
UMLS CUI [1]
C1299487
Patient address
Beskrivning

Patient address

Datatyp

text

Alias
UMLS CUI [1]
C0421449
Patient Birth Date
Beskrivning

Patient Birth Date

Datatyp

date

Alias
UMLS CUI [1]
C0421451
Insurance ID
Beskrivning

Insurance ID

Datatyp

integer

Alias
UMLS CUI [1]
C1547687
Insurance number
Beskrivning

Insurance number

Datatyp

integer

Alias
UMLS CUI [1]
C1549712
Status
Beskrivning

Status

Datatyp

integer

Alias
UMLS CUI [1]
C0449438
Facility number
Beskrivning

Facility number

Datatyp

integer

Alias
UMLS CUI [1]
C1549700
Physician ID number
Beskrivning

Physician ID number

Datatyp

integer

Alias
UMLS CUI [1]
C1548646
Date
Beskrivning

Date

Datatyp

date

Alias
UMLS CUI [1]
C0011008
Cost coverage application form
Beskrivning

Cost coverage application form

Cost coverage application form
Beskrivning

Cost coverage application form

Datatyp

integer

Alias
UMLS CUI [1]
C1555849
Medical prescription for rehabilitation sports / functional training
Beskrivning

Medical prescription for rehabilitation sports / functional training

diagnoses
Beskrivning

diagnoses

Datatyp

text

Alias
UMLS CUI [1]
C0011900
body malfunction
Beskrivning

body malfunction

Datatyp

text

Alias
UMLS CUI [1]
C0231174
rehabilitation sports objective
Beskrivning

rehabilitation sports objective

Datatyp

text

Alias
UMLS CUI [1]
C0679840
Recommended sport
Beskrivning

Recommended sport

gymnastics
Beskrivning

gymnastics

Datatyp

boolean

Alias
UMLS CUI [1]
C0018409
swimming
Beskrivning

swimming

Datatyp

boolean

Alias
UMLS CUI [1]
C0039003
athletics
Beskrivning

athletics

Datatyp

boolean

Alias
UMLS CUI [1]
C1510656
movement games
Beskrivning

movement games

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0150593
UMLS CUI [1,2]
C0026649
other sport
Beskrivning

other sport

Datatyp

text

Alias
UMLS CUI [1]
C0038039
Self-confidence enhancement
Beskrivning

Self-confidence enhancement

Datatyp

boolean

Alias
UMLS CUI [1]
C2315340
Rehabilitation sports indication
Beskrivning

Rehabilitation sports indication

50 workout
Beskrivning

50 workout

Datatyp

boolean

Alias
UMLS CUI [1]
C0220931
120 workouts if indicated
Beskrivning

120 workouts if indicated

Datatyp

boolean

Alias
UMLS CUI [1]
C0220931
rehabilitation sport indication
Beskrivning

rehabilitation sport indication

Datatyp

integer

Alias
UMLS CUI [1,1]
C0220931
UMLS CUI [1,2]
C0392360
28 workouts for self-confidence enhancement
Beskrivning

28 workouts for self-confidence enhancement

Datatyp

boolean

Alias
UMLS CUI [1]
C2315340
other workout volume
Beskrivning

other workout volume

Datatyp

integer

Alias
UMLS CUI [1]
C0220931
120 workouts
Beskrivning

120 workouts

Datatyp

boolean

Alias
UMLS CUI [1]
C0220931
Recommended functional sports
Beskrivning

Recommended functional sports

dry gymnastics
Beskrivning

dry gymnastics

Datatyp

boolean

Alias
UMLS CUI [1]
C0018409
water gymnastics
Beskrivning

water gymnastics

Datatyp

boolean

Alias
UMLS CUI [1]
C0018409
Functional sports indication
Beskrivning

Functional sports indication

12 months of training
Beskrivning

12 months of training

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0449238
UMLS CUI [1,2]
C0038039
24 months of training
Beskrivning

24 months of training

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0449238
UMLS CUI [1,2]
C0038039
impairment as indication for functional training
Beskrivning

impairment as indication for functional training

Datatyp

integer

Alias
UMLS CUI [1,1]
C0220931
UMLS CUI [1,2]
C0392360
24 months training
Beskrivning

24 months training

Datatyp

boolean

Alias
UMLS CUI [1]
C0220931
other indications for rehabilitation sports
Beskrivning

other indications for rehabilitation sports

Datatyp

text

Alias
UMLS CUI [1,1]
C0220931
UMLS CUI [1,2]
C0392360
Rehabilitation sports
Beskrivning

Rehabilitation sports

rehabilitation sport
Beskrivning

rehabilitation sport

Datatyp

integer

Alias
UMLS CUI [1]
C1555849
other workout volume
Beskrivning

other workout volume

Datatyp

integer

Alias
UMLS CUI [1]
C0220931
Recommended workout frequency for rehabilitation sports/functional training
Beskrivning

Recommended workout frequency for rehabilitation sports/functional training

Datatyp

text

Alias
UMLS CUI [1,1]
C1555849
UMLS CUI [1,2]
C0439603
justification
Beskrivning

justification

Datatyp

text

Alias
UMLS CUI [1,1]
C1555849
UMLS CUI [1,2]
C0439603
UMLS CUI [1,3]
C0392360
Footer
Beskrivning

Footer

Signature date
Beskrivning

Signature date

Datatyp

date

Alias
UMLS CUI [1]
C0807937
Cost Coverage application
Beskrivning

Cost Coverage application

service provider
Beskrivning

service provider

Datatyp

text

Alias
UMLS CUI [1]
C0679886
rehabilitation sport since
Beskrivning

rehabilitation sport since

Datatyp

date

Alias
UMLS CUI [1,1]
C1555849
UMLS CUI [1,2]
C2708155
Signature date
Beskrivning

Signature date

Datatyp

date

Måttenheter
  • TT-MM-JJ
Alias
UMLS CUI [1]
C0807937
TT-MM-JJ
Cost Coverage declaration
Beskrivning

Cost Coverage declaration

rehabilitation sports
Beskrivning

rehabilitation sports

Datatyp

boolean

Alias
UMLS CUI [1]
C1555849
rehabilitation sports volume
Beskrivning

rehabilitation sports volume

Datatyp

integer

Alias
UMLS CUI [1,1]
C1555849
UMLS CUI [1,2]
C0220931
other rehabilitation sport volume
Beskrivning

other rehabilitation sport volume

Datatyp

integer

Alias
UMLS CUI [1,1]
C1555849
UMLS CUI [1,2]
C0220931
Functional training
Beskrivning

Functional training

Datatyp

boolean

Alias
UMLS CUI [1,1]
C0203967
UMLS CUI [1,2]
C0332307
functional training volume
Beskrivning

functional training volume

Datatyp

integer

Alias
UMLS CUI [1,1]
C0589106
UMLS CUI [1,2]
C0439603
functional training duration
Beskrivning

functional training duration

Datatyp

integer

Alias
UMLS CUI [1,1]
C0449238
UMLS CUI [1,2]
C0589106
other functional training duration
Beskrivning

other functional training duration

Datatyp

integer

Alias
UMLS CUI [1,1]
C0449238
UMLS CUI [1,2]
C0589106
physical therapy start date
Beskrivning

physical therapy start date

Datatyp

date

Alias
UMLS CUI [1]
C2708155
physical therapy end date
Beskrivning

physical therapy end date

Datatyp

date

Alias
UMLS CUI [1]
C2708157
Footer
Beskrivning

Footer

Signature date
Beskrivning

Signature date

Datatyp

date

Alias
UMLS CUI [1]
C0807937
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Similar models

KBV Cost Coverage Application form Template 56

1 Formulär
Name
Typ
Description | Question | Decode (Coded Value)
Datatyp
Alias
Item Group
Health Insurance name
Item
text
C0021682 (UMLS CUI [1])
Patient surname
Item
text
C0421448 (UMLS CUI [1])
Patient Name
Item
text
C1299487 (UMLS CUI [1])
Patient address
Item
text
C0421449 (UMLS CUI [1])
Patient Birth Date
Item
date
C0421451 (UMLS CUI [1])
Insurance ID
Item
integer
C1547687 (UMLS CUI [1])
Insurance number
Item
integer
C1549712 (UMLS CUI [1])
Status
Item
integer
C0449438 (UMLS CUI [1])
Facility number
Item
integer
C1549700 (UMLS CUI [1])
Physician ID number
Item
integer
C1548646 (UMLS CUI [1])
Date
Item
date
C0011008 (UMLS CUI [1])
Item
integer
C1555849 (UMLS CUI [1])
Cost absorption application form
Code List
Cost coverage application form
CL Item
 (1)
CL Item
 (2)
diagnoses
Item
text
C0011900 (UMLS CUI [1])
body malfunction
Item
text
C0231174 (UMLS CUI [1])
rehabilitation sports objective
Item
text
C0679840 (UMLS CUI [1])
gymnastics
Item
boolean
C0018409 (UMLS CUI [1])
swimming
Item
boolean
C0039003 (UMLS CUI [1])
athletics
Item
boolean
C1510656 (UMLS CUI [1])
movement games
Item
boolean
C0150593 (UMLS CUI [1,1])
C0026649 (UMLS CUI [1,2])
other sport
Item
text
C0038039 (UMLS CUI [1])
Self-confidence enhancement
Item
boolean
C2315340 (UMLS CUI [1])
50 workout
Item
boolean
C0220931 (UMLS CUI [1])
120 workouts if indicated
Item
boolean
C0220931 (UMLS CUI [1])
Item
integer
C0220931 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
rehabilitation sport indication
Code List
rehabilitation sport indication
CL Item
 (1)
CL Item
 (2)
CL Item
 (3)
CL Item
 (4)
CL Item
 (5)
CL Item
 (6)
CL Item
 (7)
CL Item
 (8)
CL Item
 (9)
CL Item
 (10)
CL Item
 (11)
CL Item
 (12)
CL Item
 (13)
CL Item
 (14)
CL Item
 (15)
CL Item
 (16)
CL Item
 (17)
28 workouts for self-confidence enhancement
Item
boolean
C2315340 (UMLS CUI [1])
other workout volume
Item
integer
C0220931 (UMLS CUI [1])
120 workouts
Item
boolean
C0220931 (UMLS CUI [1])
dry gymnastics
Item
boolean
C0018409 (UMLS CUI [1])
water gymnastics
Item
boolean
C0018409 (UMLS CUI [1])
12 months of training
Item
boolean
C0449238 (UMLS CUI [1,1])
C0038039 (UMLS CUI [1,2])
24 months of training
Item
boolean
C0449238 (UMLS CUI [1,1])
C0038039 (UMLS CUI [1,2])
Item
integer
C0220931 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
impairment as indication for functional training
Code List
impairment as indication for functional training
CL Item
 (1)
CL Item
 (2)
CL Item
 (3)
CL Item
 (4)
CL Item
 (5)
CL Item
 (6)
CL Item
 (7)
24 months training
Item
boolean
C0220931 (UMLS CUI [1])
other indications for rehabilitation sports
Item
text
C0220931 (UMLS CUI [1,1])
C0392360 (UMLS CUI [1,2])
Item
integer
C1555849 (UMLS CUI [1])
rehabilitation sport
Code List
rehabilitation sport
CL Item
 (1)
CL Item
 (2)
CL Item
 (3)
CL Item
 (4)
other workout volume
Item
integer
C0220931 (UMLS CUI [1])
Item
text
C1555849 (UMLS CUI [1,1])
C0439603 (UMLS CUI [1,2])
Recommended workout frequency for rehabilitation sports/functional training
Code List
Recommended workout frequency for rehabilitation sports/functional training
CL Item
 (1 mal)
CL Item
 (2 mal)
CL Item
 (3 mal)
justification
Item
text
C1555849 (UMLS CUI [1,1])
C0439603 (UMLS CUI [1,2])
C0392360 (UMLS CUI [1,3])
Item Group
Signature date
Item
Signature date
date
C0807937 (UMLS CUI [1])
service provider
Item
text
C0679886 (UMLS CUI [1])
rehabilitation sport since
Item
date
C1555849 (UMLS CUI [1,1])
C2708155 (UMLS CUI [1,2])
Signature date
Item
date
C0807937 (UMLS CUI [1])
rehabilitation sports
Item
boolean
C1555849 (UMLS CUI [1])
Item
integer
C1555849 (UMLS CUI [1,1])
C0220931 (UMLS CUI [1,2])
rehabilitation sports volume
Code List
rehabilitation sports volume
CL Item
 (1)
CL Item
 (2)
CL Item
 (3)
CL Item
 (4)
CL Item
 (5)
other rehabilitation sport volume
Item
integer
C1555849 (UMLS CUI [1,1])
C0220931 (UMLS CUI [1,2])
Functional training
Item
boolean
C0203967 (UMLS CUI [1,1])
C0332307 (UMLS CUI [1,2])
Item
integer
C0589106 (UMLS CUI [1,1])
C0439603 (UMLS CUI [1,2])
functional training volume
Code List
functional training volume
CL Item
 (1)
CL Item
 (2)
CL Item
 (3)
Item
integer
C0449238 (UMLS CUI [1,1])
C0589106 (UMLS CUI [1,2])
functional training volume
Code List
functional training duration
CL Item
 (1)
CL Item
 (2)
other functional training duration
Item
integer
C0449238 (UMLS CUI [1,1])
C0589106 (UMLS CUI [1,2])
physical therapy start date
Item
date
C2708155 (UMLS CUI [1])
physical therapy end date
Item
date
C2708157 (UMLS CUI [1])
Item Group
Signature date
Item
Signature date
date
C0807937 (UMLS CUI [1])
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