ERE: View / Submit CE Request, Social Security

Priority Request

Immediate response needed.

Patient Name: DOE, TESTCASE2001
Patient DOB: 10/20/1979
Request Type: Consultative Exam
Request ID: 20140805172441_728066
Requesting Office: WI - Wisconsin DDS [S56]
Location: 1506 Woodlawn Drive test
maryfield, Ellicott, MD 21045

Patient SSN: XXX-XX-2001
Provider Name: A CE Provider
Request Date: 06/30/2010
Disability Examiner: testExaminer
CE Appt Date & Time: 07/25/2010 11:24 AM

Service Items

Service Item 1:

Item Description: test104

Item Code: 200

Service Item 2:

Item Description: test105

Item Code: 201

Service Item 3:

Item Description: test106

Item Code: 202

Request Details

What's Changed:

Special Instructions:

VAL CE Report Test for ERE Release

Documentation:

File Name	Date Added
Request Letter	08/05/2014
Authorization To Disclose Information	08/05/2014
Supporting Documentation	08/05/2014

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Prepare Report for Provider

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Reason for No Show Response:

No contact with patient
Patient cancelled appointment (provide reason if known)
Patient showed up for appointment, but could not be evaluated (comments required)
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