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NEBRASKA MEDICAID PROGRAM REQUEST FOR PRIOR AUTHORIZATION OF PAYMENT Single Entity or Combination BRAND NAME COX I (NOTE: Generic COX I NSAIDs do NOT require prior authorization.) PRESCRIBING PHYSICIAN:
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Start by gathering all the necessary information, such as the date, time, and location of the note.
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Begin with the patient's personal information, including their name, address, and contact details.
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Include the patient's medical history, any current medications they are taking, and any relevant allergies or pre-existing conditions.
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Provide a detailed description of the reason for the note, including any symptoms or concerns expressed by the patient.
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Record the findings of any examinations or tests conducted, along with any observations made during the evaluation.
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Include any recommended treatment plans, medications, or follow-up appointments.
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Sign and date the note to certify its completion and authenticity.
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Medical professionals, including doctors, nurses, and other healthcare providers, who are responsible for documenting patient visits and maintaining accurate medical records.
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