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GLAUCOMA CO-MANAGEMENT SUMMARY REPORT FORM
RSA 327:6-C
OD_________________________ Patient Initials_______________ Patient
ID#__________
MD_________________________Date_________________
I,
__________________________, MD, certify that
____________________________, OD,
has successfully managed the glaucoma of patient (ID#)______________,
for 18 months,
from (date) ___ ___ ___ to ___ ___ ___.
During this period of time, I have personally evaluated the patient
_____ times. In addition
to evaluation findings, I have either performed and/or reviewed the
diagnostic testing and
therapeutic decisions for the successful co-management of this case.
Additional comments:
________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Signature
________________________ Date______________
I,
______________________________________, OD, certify that I have
co-managed
patient (ID#)_____________ for 18 months with __________________________
,MD
Signature
________________________ Date______________
DISQUALIFICATION STATEMENT
As
the co-managing ophthalmologist, I petition the JPFCC to disqualify
patient
(ID#) ____________ as successfully co-managed.
Signature
________________________ Date______________
I, _________________________, OD, appeal/do not appeal to the JPFCC for
reconsideration of the disqualification of patient (ID#) ______________
by ___________________, MD.
Signature
________________________ Date______________
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