Priority Request

Immediate response needed.
Patient Name: TESTCASE2001 DOE
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 , 21045
Patient SSN: XXX-XX-2001
Provider Name: Mr Test test test
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

Request Response

Was a Consultative Exam performed?

Add Reason

Reason for No Show Response:

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  • File types accepted: .wpd, .doc, .docx, .txt, .xls, .xlsx, .pdf, .rtf, .tiff, .tif
  • Please do not upload password-protected files because they cannot be processed.

Additional Information

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Consultative Examination Authorization Agreement

Please read this statement and indicate your understanding by checking the "I have read and agree to the above" checkbox below. When you select "Submit", you will generate an electronic signature and submit 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. I have a valid license and have not been federally excluded. The report is accurate. By checking the "I have read and agree to the above" 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.