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Medical Report Template

This document provides contact information for two St. Luke's Medical Center referral offices in Quezon City and Global City. It also contains a medical report form for physicians to submit to document services provided to TakeCare patients. The form requests patient information, date and location of services, clinical details, diagnosis and procedure codes, treatment plan, and requires the physician's signature and contact information. Claims must be submitted within 45 days of service or discharge to avoid denial for stale billing.

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Kimny Perez
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8K views1 page

Medical Report Template

This document provides contact information for two St. Luke's Medical Center referral offices in Quezon City and Global City. It also contains a medical report form for physicians to submit to document services provided to TakeCare patients. The form requests patient information, date and location of services, clinical details, diagnosis and procedure codes, treatment plan, and requires the physician's signature and contact information. Claims must be submitted within 45 days of service or discharge to avoid denial for stale billing.

Uploaded by

Kimny Perez
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • Description of Services
  • Patient Information
  • Clinical Information
  • Recommendation
  • Diagnosis

Medical Referral Office – Quezon City Medical Referral Office / Provider Relations Office– Global City

St. Luke’s Medical Center-Quezon City St. Luke’s Medical Center-Global City
CHBC North Tower Room 718 Medical Arts Bldg. (MAB) Room 725-726
Trunk line: (632) 723-0101 Local 5718 Trunk line: (632) 789-7700 Local 7725 / 7726
Direct line: (632) 726-5770 Direct line: (632) 8467508
Fax: (632) 726-6130 Fax: (632) 846-6335
Office Hours: 8 AM-5 PM, Monday-Friday Office Hours: 8 AM-5 PM, Monday-Friday

MEDICAL REPORT
(Note to TakeCare Physician Provider: This serves as your PROFESSIONAL FEE SLIP)

PATIENT’S NAME: Last: _______________________ First: ______________________ Middle: ___________________

DESCRIPTION OF SERVICES:
[ ] OUTPATIENT [ ] INPATIENT
[ ] Consultation [ ] Medical Management
[ ] Pre-Operative Clearance [ ] Surgical Procedure / Management
[ ] Surgical Procedure [ ] Non-Surgical / Diagnostic Procedure
[ ] Non-Surgical / Diagnostic Procedure [ ] Anesthesia / Sedation
[ ] Anesthesia / Sedation
DATE/S OF SERVICE/S: FACILITY: [ ] SLMC - QC [ ] SLMC - GC [ ] MMC
[ ] CDUH [ ] TMC - ORTIGAS [ ] TMC - CLARK
[ ] TMC- ILOILO [ ] OTHERS ___________________
CLINICAL INFORMATION:
Clinical History and Findings (Please attach consult report, medical abstract, operative report, test results, etc.):

Diagnosis/es (Please include ICD-10 Code/s.): Procedure/s done (Please include CPT code/s.):
1. 1.
2. 2.
3. 3.
4. 4.
5. 5.

Plan / Recommendations / Prescribed Medication/s:

Note: Professional fee slips for services rendered must be submitted no more than forty-five (45) days from date of service or date of
discharge with appropriate and complete documentation necessary for review and pricing. Claims received after forty-five (45) days
from date of service filing limit will be denied as stale billing.

_______________________________________________ _____________________________
PHYSICIAN’S NAME AND SIGNATURE / DATE E-mail Add. / Contact Info

White – TakeCare Copy Pink – Patient’s Copy Blue – Physician’s Copy

PI_MRO form_2014

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