Get the free Physician Notification Form CO-1317 - osc ct

State of Connecticut Health Enhancement Program CO-1317 REV 5/2013 PHYSICIAN NOTIFICATION FORM Important Information This form should be used if your provider does not feel it is clinically appropriate

How to fill out physician notification form co-1317

How to fill out physician notification form co-1317:

1. Start by providing your personal information such as your full name, address, and contact details in the specified fields on the form.
2. Next, indicate the date of the notification in the corresponding section.
3. Provide the details of your physician, including their name, address, and contact information.
4. Specify the reason for the notification, whether it is for a diagnosis, treatment, or any other medical purpose.
5. Describe the medical condition or issue that requires the physician's notification accurately and clearly.
6. If applicable, attach any supporting medical documentation to strengthen your case or provide further explanation.
7. Review the form to ensure all the necessary information is complete and accurate.
8. Sign and date the form to certify the accuracy of the provided information.

Who needs physician notification form co-1317:

1. Individuals who are undergoing medical diagnosis or treatment and require the involvement of a physician.
2. Patients who need to inform their physician regarding any changes in their medical conditions or treatment plans.
3. Healthcare providers who are responsible for keeping track of their patients' medical progress and need documentation of the physician's notification for proper records maintenance.

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