Informed Choice to Not Undergo Recommended Treatment or Procedure “Not Covered Benefit” (Sample Letter)

LETTER TO PATIENT REGARDING INFORMED CHOICE NOT TO UNDERGO A RECOMMENDED TREATMENT/PROCEDURE

Patient Name

Patient Address

Dear (Patient Name):

On (Date), I prescribed (Test/Procedure). On (Date), (Name of PPO, IPA, HMO) did not consider the test/procedure a covered benefit and denied payment authorization for same. On that basis, you have informed me of your decision to forego the (Treatment/Procedure) I have prescribed. I expressed my concerns regarding your decision during our discussion on (Date) about the potential ramifications of your informed choice not to undergo the (Test/Procedure).

According to my best medical judgment, I recommend that you undergo the procedure regardless of the denial of benefits by (Name of PPO, IPA, HMO). You have the right to appeal the decision of (Name of PPO, IPA, HMO) should you choose to do so.

Should you wish to discuss this further, please do not hesitate to contact me.

Sincerely yours,

(Your Name)

Informed Choice to Not Undergo Recommended Treatment or Procedure “Not Medically Necessary” (Sample Letter)

LETTER TO PATIENT REGARDING INFORMED CHOICE

Patient Name

Patient Address

Dear (Patient Name):

On (Date), I prescribed (Test/Procedure). On (Date), (Name of PPO, IPA, HMO) did not consider the test/procedure medically necessary and denied payment authorization for same. On that basis, you have informed me of your decision to forego the (Treatment/Procedure) I have prescribed. I expressed my concerns regarding your decision during our discussion on (Date) about the potential ramifications of your informed choice not to undergo the (Test/Procedure).

According to my best medical judgment, I recommend that you undergo the procedure regardless of the denial of benefits by (Name of PPO, IPA, HMO ). You have the right to appeal the decision of (Name of PPO, IPA, HMO) should you choose to do so.

Should you wish to discuss this further, please do not hesitate to contact me.

Sincerely yours,

(Your Name)

Referral Form for Managed Care Patients

REFERRAL FORM FOR MANAGED CARE PATIENTS

Date:                                                  

Dr.                                                        has referred you to Dr.                                              

Phone:                                                

This referral is:

                                          Emergency

                                           Urgent (24-48 hours)

                                           Timely (1-2 weeks)

                                           When convenient

This appointment will have to be made for you by your primary care physician,

Dr.                                                       , who has been notified.  If there are any problems scheduling this appointment, please contact this office.

For office use only:

Outcome:                                                                                                                                           

(Original to patient. Copy to chart.)

General Anesthesia

INFORMATION REGARDING GENERAL ANESTHESIA

I    (the patient, or person authorized to sign for the patient)     have been informed that the proposed surgery will be performed under general anesthesia. Although my doctor will not be administering the general anesthesia himself, he has told me that it will be administered by a qualified and licensed individual. I have been made aware of the need for this type of anesthesia and have been informed by my doctor of the following facts about general anesthesia: 

• General anesthesia produces an unconscious state; the whole body is affected. This type of anesthesia is produced by injecting drugs into the patient’s blood stream and by having the patient inhale other drugs (anesthetic gas).
• Frequently, the person who administers the anesthetic places a tube through the mouth or nose of the patient into the trachea (windpipe) to aid in managing the patient’s breathing (oxygen needs) and amount of the anesthetic gas. Occasionally, on recovering from general anesthesia, the patient will note soreness and pain in the mouth and throat areas from abrasions. If it is necessary to place a tube through the nose, nosebleeds may occur.
• Although very rare, strokes, brain damage, heart attacks and pneumonia are known complications of general anesthesia. All types of anesthesia involve some risk. Complications from all forms of anesthesia are rare, but may occur. There is a very remote possibility of death as a complication of general anesthesia.
• Other known complications of general anesthesia include (but are not limited to) broken teeth, allergic reactions, infection, liver failure, kidney damage, bleeding, blood clots, loss of limb function and paralysis.
• General anesthesia complications occur rarely. They can happen, unpredictably, regardless of the experience, care and skill of the anesthesia provider.

X                                                                                             X                                            

Patient (or person authorized to sign for patient)           Date

[Document in the patient’s chart that he/she received information regarding general anesthesia.]

Ozurdex

This sample consent form for Ozurdex  is written in plain language to make it easier for patients to understand.    

SAVE THIS FORM TO YOUR COMPUTER BY USING THE DOWNLOAD BUTTON.

 Perform a time out before each intravitreal injection.

OMIC has received reports of “wrong” events associated with intravitreal injections. These include wrong patient, wrong eye, wrong condition, wrong drug, and wrong dose.

To ensure that the correct drug and dose are injected into the correct eye every time, the ophthalmologist needs to lead a time out. Time out before intravitreal injections provides the opportunity to confirm that the patient, medical record, and ophthalmologist are in agreement.