ID

25619

Descripción

Muster 56 - Antrag auf Kostenübernahme (Freigabe 01.09.2014). 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 56 - Cost Absorption Application Form (Released 01-09-2014). 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

Palabras clave

Versiones (4)
  1. 16/1/17 16/1/17 -
  2. 16/1/17 16/1/17 -
  3. 28/1/17 28/1/17 -
  4. 7/9/17 7/9/17 -
Titular de derechos de autor

KBV

Subido en

7 de septiembre de 2017

DOI

Para solicitar uno, por favor iniciar sesión.

Licencia

Creative Commons BY-NC 3.0
Comentarios del modelo :

Puede comentar sobre el modelo de datos aquí. A través de las burbujas de diálogo en los grupos de elementos y elementos, puede agregar comentarios específicos.

Volver a los comentarios del modelo
Comentarios de grupo de elementos para :

Comentarios del elemento para :

Para descargar modelos de datos, debe haber iniciado sesión. Por favor iniciar sesión o Registrate gratis.

KBV Cost Coverage Application form Template 56

Alemán Inglés

KBV Cost Coverage Application form Template 56

1 formularios  
Header
Descripción

Header

Health Insurance name
Descripción

Health Insurance name

Tipo de datos

text

Alias
UMLS CUI [1]
C0021682
Patient surname
Descripción

Patient surname

Tipo de datos

text

Alias
UMLS CUI [1]
C0421448
Patient Name
Descripción

Patient Name

Tipo de datos

text

Alias
UMLS CUI [1]
C1299487
Patient address
Descripción

Patient address

Tipo de datos

text

Alias
UMLS CUI [1]
C0421449
Patient Birth Date
Descripción

Patient Birth Date

Tipo de datos

date

Alias
UMLS CUI [1]
C0421451
Insurance ID
Descripción

Insurance ID

Tipo de datos

integer

Alias
UMLS CUI [1]
C1547687
Insurance number
Descripción

Insurance number

Tipo de datos

integer

Alias
UMLS CUI [1]
C1549712
Status
Descripción

Status

Tipo de datos

integer

Alias
UMLS CUI [1]
C0449438
Facility number
Descripción

Facility number

Tipo de datos

integer

Alias
UMLS CUI [1]
C1549700
Physician ID number
Descripción

Physician ID number

Tipo de datos

integer

Alias
UMLS CUI [1]
C1548646
Date
Descripción

Date

Tipo de datos

date

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

Cost coverage application form

Cost coverage application form
Descripción

Cost coverage application form

Tipo de datos

integer

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

Medical prescription for rehabilitation sports / functional training

diagnoses
Descripción

diagnoses

Tipo de datos

text

Alias
UMLS CUI [1]
C0011900
body malfunction
Descripción

body malfunction

Tipo de datos

text

Alias
UMLS CUI [1]
C0231174
rehabilitation sports objective
Descripción

rehabilitation sports objective

Tipo de datos

text

Alias
UMLS CUI [1]
C0679840
Recommended sport
Descripción

Recommended sport

gymnastics
Descripción

gymnastics

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0018409
swimming
Descripción

swimming

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0039003
athletics
Descripción

athletics

Tipo de datos

boolean

Alias
UMLS CUI [1]
C1510656
movement games
Descripción

movement games

Tipo de datos

boolean

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

other sport

Tipo de datos

text

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

Self-confidence enhancement

Tipo de datos

boolean

Alias
UMLS CUI [1]
C2315340
Rehabilitation sports indication
Descripción

Rehabilitation sports indication

50 workout
Descripción

50 workout

Tipo de datos

boolean

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

120 workouts if indicated

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0220931
rehabilitation sport indication
Descripción

rehabilitation sport indication

Tipo de datos

integer

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

28 workouts for self-confidence enhancement

Tipo de datos

boolean

Alias
UMLS CUI [1]
C2315340
other workout volume
Descripción

other workout volume

Tipo de datos

integer

Alias
UMLS CUI [1]
C0220931
120 workouts
Descripción

120 workouts

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0220931
Recommended functional sports
Descripción

Recommended functional sports

dry gymnastics
Descripción

dry gymnastics

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0018409
water gymnastics
Descripción

water gymnastics

Tipo de datos

boolean

Alias
UMLS CUI [1]
C0018409
Functional sports indication
Descripción

Functional sports indication

12 months of training
Descripción

12 months of training

Tipo de datos

boolean

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

24 months of training

Tipo de datos

boolean

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

impairment as indication for functional training

Tipo de datos

integer

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

24 months training

Tipo de datos

boolean

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

other indications for rehabilitation sports

Tipo de datos

text

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

Rehabilitation sports

rehabilitation sport
Descripción

rehabilitation sport

Tipo de datos

integer

Alias
UMLS CUI [1]
C1555849
other workout volume
Descripción

other workout volume

Tipo de datos

integer

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

Recommended workout frequency for rehabilitation sports/functional training

Tipo de datos

text

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

justification

Tipo de datos

text

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

Footer

Signature date
Descripción

Signature date

Tipo de datos

date

Alias
UMLS CUI [1]
C0807937
Cost Coverage application
Descripción

Cost Coverage application

service provider
Descripción

service provider

Tipo de datos

text

Alias
UMLS CUI [1]
C0679886
rehabilitation sport since
Descripción

rehabilitation sport since

Tipo de datos

date

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

Signature date

Tipo de datos

date

Unidades de medida
  • TT-MM-JJ
Alias
UMLS CUI [1]
C0807937
TT-MM-JJ
Cost Coverage declaration
Descripción

Cost Coverage declaration

rehabilitation sports
Descripción

rehabilitation sports

Tipo de datos

boolean

Alias
UMLS CUI [1]
C1555849
rehabilitation sports volume
Descripción

rehabilitation sports volume

Tipo de datos

integer

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

other rehabilitation sport volume

Tipo de datos

integer

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

Functional training

Tipo de datos

boolean

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

functional training volume

Tipo de datos

integer

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

functional training duration

Tipo de datos

integer

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

other functional training duration

Tipo de datos

integer

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

physical therapy start date

Tipo de datos

date

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

physical therapy end date

Tipo de datos

date

Alias
UMLS CUI [1]
C2708157
Footer
Descripción

Footer

Signature date
Descripción

Signature date

Tipo de datos

date

Alias
UMLS CUI [1]
C0807937
Volver a la parte superior de la página

Similar models

KBV Cost Coverage Application form Template 56

1 formularios
Name
Tipo
Description | Question | Decode (Coded Value)
Tipo de datos
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])
Volver a la parte superior de la página 

Contacto

Utilice este formulario para comentarios, preguntas y sugerencias.

Los campos marcados con * son obligatorios.

Ayuda

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