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Health Insurance Company Report Template
Kevin McNamee, D.C., L.Ac.

This is a template to help you write a health insurance company report.  Click here to download and save the template.

 

<Date>

<Insurance Company Name>
<Address>
<City, State Zip>

Re:  <Patient’s Name>
Claim Number:  <                        >
Chief Complaint:

1.<list area of complaint>
2.<list area of complaint>
3.<list area of complaint>
4.<list area of complaint>

Subjective: Provide the history including:

  • date of initial onset
  • how the condition began
  • body part involved and the associated frequency (absent, occasional, intermittent, or constant), intensity (none, slight, moderate or severe), and duration
  • what increases and decreases the symptoms
  • describe the pain quality (sharp, dull, throbbing, achy, numbness, burning, tingling)
  • radiation from where to where and how long it lasts
  • change in the symptoms based on the patient’s location during the day
  • change in the symptoms base on the time of day

The patient was first seen in this office on <list first date seen in your office for this onset> for examination, treatment for the above chief complaints.  At that time

[For each chief complaint listed above use this paragraph to describe the subjective. Keep the same order as the chief complaints listed above.]

The <body part involved> pain began on <date > when the patient <describe how it happened>.

The pain was described as <occasionally, intermittently or constantly>  <sharp, dull, throbbing, achy, numbness, burning tingling> that increased with  < list >  and decreased with  <list >

A)  There was no radiation in this area. OR
B)
  The pain traveled from <list > to <list > and lasted for < seconds, minutes, hours, days > when it occurs.

A)  There was no change in the pain with change in the patient’s location during the day. OR
B)
  The pain increased when the patient <describe the location> and increased when the patient was <describe the location>.

A)  There was no change with the time of day. OR
B)
The pain was <absent, present, increased, decreased> in the <morning, late morning, afternoon, evening, night time>.

Past history showed <list any motor vehicle accidents, surgeries, hospitalizations which have a bearing on the complaints> and <has / has no> residuals form these. 

Treatment has consisted of <list the therapies> which have been administered at <home, office, health providers office>.

The patient was last seen in this office on <list the last treatment date>.  At that time the patient had <list the subjective complaints frequency, intensity and duration>.

Laboratory Tests:

No laboratory tests have been performed for this injury.  OR

A <list the laboratory test> was/were performed on <list the date of the test> which showed no abnormalities. OR

A <list the laboratory test> was/were performed on <list the date of the test> which showed the following to be increased: <list the ones which are increased>; and the following to be decreased: <list the ones which are decreased>.

Progress and Discussion:

<Summarize the highlights of the patient’s subjective and objectives for each of the chief complaints when they were originally seen in your office.>

After a clinical course of <list the number of treatments since the last evaluation> treatments  consisting of <list the therapies>, the patient was re-evaluated on <give date of re-eval>.

[Select the ones below that apply to your patient’s treatment response.]

A) The evaluation showed <no, little, some, good, excellent> improvement in <list the subjective and objective improvements and body area>.

B) There was < no change/worsening> in <list the subjective and objective for the body areas>.

C)  The patient is still in need of treatment consisting of <list the therapies>.  Over the next <list the number of days/weeks> I anticipate the patient will need <number of visits> treatments.

D)  The patient’s progress has been <good/steady/slow/poor>.

E)  The patient’s condition is improving as well as can be expected considering the nature of the injury.

F)  The patient is impaired due to <list the cause>.

G)  The patient plans to return to work on <date>.

H)  The patient <is / is not> disabled from work.

I)  The patient is released as of <date> to return to work with <full/restricted> duties. Work restrictions include <list the activity and how long they can/cannot do the activity>.

J)  The patient has been discharged from care at a maximum medical improvement on <date> with the following home care instructions <list the home care>.

K)  The patient has been discharged from care at a pre-injury status on <date> with the following home care instructions <list the home care>.

L) The patient was referred to <list name of the doctor>. The patient <is / is not> to return to this office for additional treatment of <list the complaint>.

M) The patient is to return to this office for additional treatment for the above chief complaints.

If you have any questions, please feel free to contact me.

Sincerely,
 

<Your Name>
 

 

 

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