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FO_MedicalNecessity_Form_Definition

This table contains the customizations for user-customized ABN form language.

These customizations assist in the establishment of a methodology for user-customized ABN form language. The form allows for up to 6 user-customized lines of text before the test list and up to 18 lines of user-customized text after the test list. The form also allows for customization of which fields appear in the form header.

This form follows the general guidelines of a multi-page ABN format. In this format the first page contains the user-customized text, and following pages are treated as addenda to the first page. The format for this form also supports having more than one ABN reason per test.

The pages following the first page of the form will not contain the footer lines. Each following page will appear as an addendum to the first page of the form and contain an addendum reference and also a place for the patient to initial.

The form design allows the user to control aspects of this form using entries in this table, FO_MedicalNecessity_Form_Definition. This table is created to support one form per record. Each record in this table allows the user to specify properties of one form. A form code value is linked to each record in this table, and can then be used to link a form to an insurance code in the FO_Ins table.

The following field values control the formatting of the flexible ABN form. Caution must be exercised to enter data in the text fields that will not exceed the length of each line of the form. The user must ensure that is the case, if not, unpredictable results may occur.

Some of the fields on this form represent properties such as bold or underline and are True/False values.

The text fields of this table allow the entry of multilingual data as long as the language characters can be found in the default windows character set.

 

Field Type Notes

MedNecForm_ID

bigint

ID field, a counter. Unique

FormCode

varchar(50)

Form code.

Enter a unique code.

Used to link the form to the FASTUI.

This link is made in a similar manner as the external form linking, using the format of 'FC = ' followed by the value of this field. This string can then be added to the medical necessity form code field of the FO_INS table to create the form link.

(what would be an example entry?)

FormDescription

varchar(255)

Form description.

Enter a description for this form.

TitleText

varchar(100)

Form title.

Enter a title for this form.

Used as the beginning line of the customized section before the test detail.

This line will be automatically bolded.

PatientNameLabelText

varchar(50)

Label for Patient Name field.

Used in the form header.

PatienIDValue

varchar(50)

Determines how to fill in the Patient ID field of the form.

Enter an allowed value.

Allowed values:

MRN

REQID

ACCESSION

ACCT

Default is REQID if this field is blank.

PtIdHide

bit

Bit flag that turns off/on the display of the Patient ID field in the form header.

Enter 0 or 1

0 = turn off display

1 = turn on display

DateOfServiceLabelText

varchar(50)

Label for DOS/Collect Date field.

Used in the form header.

DateOfServiceHide

bit

Bit flag that turns off/on the display of the DOS/Collect Date field in the form header.

Enter 0 or 1

0 = turn off display

1 = turn on display

TestColumnText

varchar(50)

Column label for Test Name field.

Used in the test detail section first column.

NotPaidColumnText

varchar(50)

Column label for Reason a Test is not Paid field.

Used in the test detail section.

CostColumnText

varchar(50)

Column label for Estimated Cost field.

Used in the test detail section.

TotalCostText

varchar(50)

Column label for Total Estimated Cost field.

Used in the test detail section.

InsNameLabelText

varchar(50)

Label for Insurance Name field.

Used in the form header.

InsNameHide

bit

Bit flag that turns off/on the display of the Insurance Name field in the form header.

Enter 0 or 1

0 = turn off display

1 = turn on display

InsNameValue

varchar(80)

Insurance Name

Overrides the insurance name from the patients table.

Provides a more generic name to be used.

InsPolicyLabelText

varchar(50)

Label for Insurance Policy Number field.

Used in the form header.

InsPolicyHide

bit

Bit flag that turns off/on the display of the Insurance Policy Number field in the form header.

Enter 0 or 1

0 = turn off display

1 = turn on display

CostEstimateColumnHide

bit

Bit flag that turns off/on the display of the Cost Estimate column in the test detail section.

Enter 0 or 1

0 = turn off display

1 = turn on display

TotalCostHide

bit

Bit flag that turns off/on the display of the Total Cost Estimate column at the end of the test detail section.

Enter 0 or 1

0 = turn off display

1 = turn on display

LogoHide

bit

Bit flag that turns off/on the display of the logo in the form header.

Enter 0 or 1

0 = turn off display

1 = turn on display

LabNameHide

bit

Bit flag that turns off/on the display of the Lab Name field in the form header.

Enter 0 or 1

0 = turn off display

1 = turn on display

LabAddressHide

bit

Bit flag that turns off/on the display of the Lab Address fields in the form header.

Enter 0 or 1

0 = turn off display

1 = turn on display

SeeAttachedPageLabelText

varchar(50)

See Attached Page label.

SignatureLabelText

varchar(50)

Signature field label.

SignatureDateLabelText

varchar(50)

Signature Date field label.

RelationshipLabelText

varchar(80)

Relationship field label.

PatientInitialsLabelText

varchar(100)

Patient Initials field label.

DateIssuedLabelText

varchar(50)

Date Issued field label.

DateIssuedHide

bit

Bit flag that turns off/on the display of the Date Issued field.

Enter 0 or 1

0 = turn off display

1 = turn on display

DateIssuedAutofillDate

bit

Bit flag that turns determines if current date fills the Date Used field.

Enter 0 or 1

0 = do not use current date

1 = use current date

ContinuedFromPageLabelText

varchar(100)

Continues from page field text.

The system will append the page number at the end of this text.

The following fields are repeated for the number of lines of User defined text that print after the title line and before the test detail section. Each group of fields allows the entry of the text for each line and is followed by true/false fields that allow for bolding and line underlining.

HdrLine1Text

varchar(100)

Header Line 1 text.

Make sure the text is not too long, that it does not cause the line to wrap.

HdrLine1Bold

bit

Bit flag that turns determines if Header Line 1 is bolded.

Enter 0 or 1

0 = do not bold

1 = bold

HdrLine1UnderLine

bit

Bit flag that turns determines if Header Line 1 is underlined.

Enter 0 or 1

0 = do not underline

1 = underline

HdrLine2Text

varchar(100)

Header Line 2 text.

Make sure the text is not too long, that it does not cause the line to wrap.

HdrLine2Bold

bit

Bit flag that turns determines if Header Line 2 is bolded.

Enter 0 or 1

0 = do not bold

1 = bold

HdrLine2UnderLine

bit

Bit flag that turns determines if Header Line 2 is underlined.

Enter 0 or 1

0 = do not underline

1 = underline

HdrLine3Text

varchar(100)

Header Line 3 text.

Make sure the text is not too long, that it does not cause the line to wrap.

HdrLine3Bold

bit

Bit flag that turns determines if Header Line 3 is bolded.

Enter 0 or 1

0 = do not bold

1 = bold

HdrLine3UnderLine

bit

Bit flag that turns determines if Header Line 3 is underlined.

Enter 0 or 1

0 = do not underline

1 = underline

HdrLine4Text

varchar(100)

Header Line 4 text.

Make sure the text is not too long, that it does not cause the line to wrap.

HdrLine4Bold

bit

Bit flag that turns determines if Header Line 4 is bolded.

Enter 0 or 1

0 = do not bold

1 = bold

HdrLine4UnderLine

bit

Bit flag that turns determines if Header Line 4 is underlined.

Enter 0 or 1

0 = do not underline

1 = underline

HdrLine5Text

varchar(100)

Header Line 5 text.

Make sure the text is not too long, that it does not cause the line to wrap.

HdrLine5Bold

bit

Bit flag that turns determines if Header Line 5 is bolded.

Enter 0 or 1

0 = do not bold

1 = bold

HdrLine5UnderLine

bit

Bit flag that turns determines if Header Line 5 is underlined.

Enter 0 or 1

0 = do not underline

1 = underline

HdrLine6Text

varchar(100)

Header Line 6 text.

Make sure the text is not too long, that it does not cause the line to wrap.

HdrLine6Bold

bit

Bit flag that turns determines if Header Line 6 is bolded.

Enter 0 or 1

0 = do not bold

1 = bold

HdrLine6UnderLine

bit

Bit flag that turns determines if Header Line 6 is underlined.

Enter 0 or 1

0 = do not underline

1 = underline

The following field groups allow up to 18 User defined lines of text to appear under the detail test list on the first page only. Each group of fields allows the entry of the text for each line and is followed by true/false fields that allow for bolding and line underlining.

FtrLine1Text

varchar(100)

Footer Line 1 text.

Make sure the text is not too long, that it does not cause the line to wrap.

FtrLine1Bold

bit

Bit flag that turns determines if Footer Line 1 is bolded.

Enter 0 or 1

0 = do not bold

1 = bold

FtrLine1UnderLine

bit

Bit flag that turns determines if Footer Line 1 is underlined.

Enter 0 or 1

0 = do not underline

1 = underline

FtrLine2Text

varchar(100)

Footer Line 2 text.

Make sure the text is not too long, that it does not cause the line to wrap.

FtrLine2Bold

bit

Bit flag that turns determines if Footer Line 2 is bolded.

Enter 0 or 1

0 = do not bold

1 = bold

FtrLine2UnderLine

bit

Bit flag that turns determines if Footer Line 2 is underlined.

Enter 0 or 1

0 = do not underline

1 = underline

FtrLine3Text

varchar(100)

Footer Line 3 text.

Make sure the text is not too long, that it does not cause the line to wrap.

FtrLine3Bold

bit

Bit flag that turns determines if Footer Line 3 is bolded.

Enter 0 or 1

0 = do not bold

1 = bold

FtrLine3UnderLine

bit

Bit flag that turns determines if Footer Line 3 is underlined.

Enter 0 or 1

0 = do not underline

1 = underline

FtrLine4Text

varchar(100)

Footer Line 4 text.

Make sure the text is not too long, that it does not cause the line to wrap.

FtrLine4Bold

bit

Bit flag that turns determines if Footer Line 4 is bolded.

Enter 0 or 1

0 = do not bold

1 = bold

FtrLine4UnderLine

bit

Bit flag that turns determines if Footer Line 4 is underlined.

Enter 0 or 1

0 = do not underline

1 = underline

FtrLine5Text

varchar(100)

Footer Line 5 text.

Make sure the text is not too long, that it does not cause the line to wrap.

FtrLine5Bold

bit

Bit flag that turns determines if Footer Line 5 is bolded.

Enter 0 or 1

0 = do not bold

1 = bold

FtrLine5UnderLine

bit

Bit flag that turns determines if Footer Line 5 is underlined.

Enter 0 or 1

0 = do not underline

1 = underline

FtrLine6Text

varchar(100)

Footer Line 6 text.

Make sure the text is not too long, that it does not cause the line to wrap.

FtrLine6Bold

bit

Bit flag that turns determines if Footer Line 6 is bolded.

Enter 0 or 1

0 = do not bold

1 = bold

FtrLine6UnderLine

bit

Bit flag that turns determines if Footer Line 6 is underlined.

Enter 0 or 1

0 = do not underline

1 = underline

FtrLine7Text

varchar(100)

Footer Line 7 text.

Make sure the text is not too long, that it does not cause the line to wrap.

FtrLine7Bold

bit

Bit flag that turns determines if Footer Line 7 is bolded.

Enter 0 or 1

0 = do not bold

1 = bold

FtrLine7UnderLine

bit

Bit flag that turns determines if Footer Line 7 is underlined.

Enter 0 or 1

0 = do not underline

1 = underline

FtrLine8Text

varchar(100)

Footer Line 8 text.

Make sure the text is not too long, that it does not cause the line to wrap.

FtrLine8Bold

bit

Bit flag that turns determines if Footer Line 8 is bolded.

Enter 0 or 1

0 = do not bold

1 = bold

FtrLine8UnderLine

bit

Bit flag that turns determines if Footer Line 8 is underlined.

Enter 0 or 1

0 = do not underline

1 = underline

FtrLine9Text

varchar(100)

Footer Line 9 text.

Make sure the text is not too long, that it does not cause the line to wrap.

FtrLine9Bold

bit

Bit flag that turns determines if Footer Line 9 is bolded.

Enter 0 or 1

0 = do not bold

1 = bold

FtrLine9UnderLine

bit

Bit flag that turns determines if Footer Line 9 is underlined.

Enter 0 or 1

0 = do not underline

1 = underline

FtrLine10Text

varchar(100)

Footer Line 10 text.

Make sure the text is not too long, that it does not cause the line to wrap.

FtrLine10Bold

bit

Bit flag that turns determines if Footer Line 10 is bolded.

Enter 0 or 1

0 = do not bold

1 = bold

FtrLine10UnderLine

bit

Bit flag that turns determines if Footer Line 10 is underlined.

Enter 0 or 1

0 = do not underline

1 = underline

FtrLine11Text

varchar(100)

Footer Line 11 text.

Make sure the text is not too long, that it does not cause the line to wrap.

FtrLine11Bold

bit

Bit flag that turns determines if Footer Line 11 is bolded.

Enter 0 or 1

0 = do not bold

1 = bold

FtrLine11UnderLine

bit

Bit flag that turns determines if Footer Line 11 is underlined.

Enter 0 or 1

0 = do not underline

1 = underline

FtrLine12Text

varchar(100)

Footer Line 12 text.

Make sure the text is not too long, that it does not cause the line to wrap.

FtrLine12Bold

bit

Bit flag that turns determines if Footer Line 12 is bolded.

Enter 0 or 1

0 = do not bold

1 = bold

FtrLine12UnderLine

bit

Bit flag that turns determines if Footer Line 12 is underlined.

Enter 0 or 1

0 = do not underline

1 = underline

FtrLine13Text

varchar(100)

Footer Line 13 text.

Make sure the text is not too long, that it does not cause the line to wrap.

FtrLine13Bold

bit

Bit flag that turns determines if Footer Line 13 is bolded.

Enter 0 or 1

0 = do not bold

1 = bold

FtrLine13UnderLine

bit

Bit flag that turns determines if Footer Line 13 is underlined.

Enter 0 or 1

0 = do not underline

1 = underline

FtrLine14Text

varchar(100)

Footer Line 14 text.

Make sure the text is not too long, that it does not cause the line to wrap.

FtrLine14Bold

bit

Bit flag that turns determines if Footer Line 14 is bolded.

Enter 0 or 1

0 = do not bold

1 = bold

FtrLine14UnderLine

bit

Bit flag that turns determines if Footer Line 14 is underlined.

Enter 0 or 1

0 = do not underline

1 = underline

FtrLine15Text

varchar(100)

Footer Line 15 text.

Make sure the text is not too long, that it does not cause the line to wrap.

FtrLine15Bold

bit

Bit flag that turns determines if Footer Line 15 is bolded.

Enter 0 or 1

0 = do not bold

1 = bold

FtrLine15UnderLine

bit

Bit flag that turns determines if Footer Line 15 is underlined.

Enter 0 or 1

0 = do not underline

1 = underline

FtrLine16Text

varchar(100)

Footer Line 16 text.

Make sure the text is not too long, that it does not cause the line to wrap.

FtrLine16Bold

bit

Bit flag that turns determines if Footer Line 16 is bolded.

Enter 0 or 1

0 = do not bold

1 = bold

FtrLine16UnderLine

bit

Bit flag that turns determines if Footer Line 16 is underlined.

Enter 0 or 1

0 = do not underline

1 = underline

FtrLine17Text

varchar(100)

Footer Line 17 text.

Make sure the text is not too long, that it does not cause the line to wrap.

FtrLine17Bold

bit

Bit flag that turns determines if Footer Line 17 is bolded.

Enter 0 or 1

0 = do not bold

1 = bold

FtrLine17UnderLine

bit

Bit flag that turns determines if Footer Line 17 is underlined.

Enter 0 or 1

0 = do not underline

1 = underline

FtrLine18Text

varchar(100)

Footer Line 18 text.

Make sure the text is not too long, that it does not cause the line to wrap.

FtrLine18Bold

bit

Bit flag that turns determines if Footer Line 18 is bolded.

Enter 0 or 1

0 = do not bold

1 = bold

FtrLine18UnderLine

bit

Bit flag that turns determines if Footer Line 18 is underlined.

Enter 0 or 1

0 = do not underline

1 = underline

CreateDate

datetime

System timestamp when record is created.

Informational

CreateUser

varchar(50)

User who created record.

Informational

EditDate

datetime

System timestamp when record is edited.

Informational

EditUser

varchar(50)

User who last edited record.

Informational

 

 

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