NP Form – Dr. Lewiecki (ID #2636)

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Sex
Ethnic Group:
Are you retired?
Have you had a bone density test?
Have you had X-rays, CT scan, or MRI of your spine?
Have you ever had X-ray therapy for any reason?
Are you interested in participating in an osteoporosis research study if you qualify?

Please indicate all medication you are currently taking or have taken in the past.

Please indicate all medication you are currently taking or have taken in the past. (copy)
Please indicate all medication you are currently taking or have taken in the past. (copy)

Please check to indicate any RECENT symptoms.

GENERAL
EYES
ENT
ENDOCRINE
RESPIRATORY
CARDIOVASCULAR
GASTROINTESTINAL
UROLOGICAL
NEUROLOGICAL
SKIN
HEMATOLOGICAL
MUSCULO-SKELETAL
OSTEOPOROSIS

Appealing Insurance Denials

I authorize NMCROC to enact appeals on my behalf to my primary and secondary (if applicable) insurance carriers as it relates to denials for the following: in-office treatment, authorized injectable medications, claim denials, prescription medication and durable medical equipment. I understand that by allowing NMCROC to appeal denials on my behalf, I am not guaranteed a positive outcome.