Patient Name: TESTCASE2222 DOE
Patient DOB: 10/20/1979
Date Prepared: 06/29/2010
Request Type: Consultative Exam
Request ID: 20140805172441_728066
Requesting Office: WI - Wisconsin DDS [S56]
Location: 1506 Woodlawn Drive test maryfield , Ellicott , 21045
Patient SSN: XXX-XX-2222
Prepared By: A CE Admin
Provider Name: Joe Ereuser
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

Special Instructions:

Files Loaded By Preparer:

File Name File Size Action
CE Report.tif 243 KB

To revise a file:

  1. Click on the file name to open
  2. Save the file to your computer
  3. Edit and save the file
  4. Attach the new file (below)
  5. Delete the original file loaded by your preparer

Attach and Upload New Files

 
  1. A maximum of 25 files can be added and all files must total less than 200MB.
  2. File types accepted: .wpd, .doc, .docx, .txt, .xls, .xlsx, .pdf, .rtf, .tiff, .tif.
  3. Please do not upload password-protected files because they cannot be processed.

The CE provider and the CE administrator can attach up to 25 files in total.

Additional Information

(16,000 characters maximum)

Consultative Examination Authorization Agreement

Please read this statement and indicate your agreement. When you select "Submit," you will generate an electronic signature for your response.

I am certifying under penalty of perjury, that I have been authorized or contracted by the Disability Determination Services to examine the claimant. The report is accurate. By checking the "I have read and agree" checkbox below, I am certifying that I personally conducted, or personally participated in conducting, the consultative examination and have electronically signed the report contained within.

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