Download Policy and Procedure Approval Form

Dear Dr: ______________________________
Date: _____________________
Please review the question below as clarification is needed to accurately reflect the severity of illness for
your patient ___ENTER PATIENT NAME HERE__who was admitted on ENTER ADMIT DATE HERE
whose medical record indicates the diagnosis of HEART FAILURE.
Based on your clinical judgment, can you further clarify the type and acuity of the
heart failure that represents the clinical indicators outlined below?
The medical record reflects the diagnosis of Heart Failure (e.g. Congestive, left, etc.) in the
(list source document(s) and date(s)):
And pertinent studies (e.g. echocardiogram, cardiac catheterization, etc.) and/or findings of
potential clinical abnormalities (e.g. physician documents an abnormal EF) shows (specify
results identified):
If specificity is known, please document the type and acuity of the heart failure for
which you are evaluating, treating, or monitoring this patient (e.g. acute and/or chronic
diastolic heart failure, acute and/or chronic systolic heart failure, acute and/or chronic diastolic
with systolic heart failure, acute on chronic diastolic and/or systolic heart failure, unspecified
heart failure, or other more appropriate diagnosis) in the box below and/or within the
medical record.
If no additional information is available please initial in or check the box, sign, date and
time.
If unable to determine, please initial in or check the box, sign, date and time.
_______________________________________ _____________
PHYSICIAN SIGNATURE
DATE
____________
TIME
Thank you for your consideration of the query. In responding to this query, please exercise your independent professional
judgment. The fact that a question is asked does not imply that any particular answer is desired or expected. If you have any
questions, please utilize the contact name below.
Contact Name: _______________________ Phone Number: ____________ Fax Number: _______________
PHYSICIAN QUERY FORM N14
(effective date: 9/1/13)
THIS FORM IS A PERMANENT PART OF THE MEDICAL RECORD
*QUERY2*
Patient Name: _______________________________
Admit Date: _______________D/C Date:_________
MR#: _____________________________________
Acct #: ____________________________________
Check here if the query generated was verbal