Table of Contents Table of Contents
Previous Page  28 / 130 Next Page
Information
Show Menu
Previous Page 28 / 130 Next Page
Page Background

28

TOC

Practice Enhancement Program

4.a Worksheet for Arranging Assessment (GP 2012)

Physicians Name: Dr. «FirstNam» «Lastname»

Phys. ID: «Phys_ID»

«Address»

«Street»

«City» «Province» «Postal»

Phone: «Phone»

Fax: «Fax»

Age: «DOB»

Name of Assessor: ____________________________________________

PROCESS

DATE

2012

1.

TYPE OF ASSESSMENT

a) Random selection b) Partner selected/Physician requested

c) 2

nd

Assessment d) prev. deferred

2.

Introduction Letter is sent to the physician to be assessed.

With this letter is sent:

a)

‘For Your Information’ sheet (orange)

b)

Physician Pre-visit Questionnaire (Q-2)

c)

Return Envelope

D/B - #1

3.

Pre-visit Questionnaire (Q-2) not returned:

If not returned within one month:

a) send 1

st

Q-2 Reminder letter

b) send 2nd Q-2 Reminder letter

c) send Final Reminder letter by Registered Mail

D/B - #2

4.

Pre-visit Questionnaire (Q-2) returned:

5.

When Pre-Visit Questionnaire (Q-2) is returned – Status is Determined

(E-Eligible; I-Ineligible; R-Retired; D-Deferred)

a) Deferral letter is sent

b) Exemption letter is sent (sometimes, depending on

reason)

6.

If Eligible, then send out Eligible letter:

With Eligible letter send:

a) Patient Questionnaire (Q-1)

b) Referred Specialist Questionnaire (Q-5)

c) Cover letters to be signed and returned (2)

d) Form for list of 60 names: Q-1a (Pt List)

e) Physical Facilities & Practice Organization Questionnaire (Q-4)

f) Full Medical Office Assessment Form for Information (R-2) (long

form)

g) Return Envelope

D/B - #3