📄 urogennp.ascx
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<%@ Control Language="c#" AutoEventWireup="false" Codebehind="UroGenNP.ascx.cs" Inherits="Caisis.UI.Modules.All.PaperForms.UroGenNP" TargetSchema="http://schemas.microsoft.com/intellisense/ie5"%>
<link href="../../../StyleSheets/formStyles.css" rel="stylesheet" type="text/css">
<div id="PaperFormStart">
<div align="center">
<div align="center">
<div align="right" class="VerticalBarCodeDiv">
<div class="VerticalBarCodeStatement"><img src="../../Images/FormImages/BarCodeLineStatement.gif" border="0" width="8" height="121"><br/>
<img src="../../Images/FormImages/BarCodeLineStatement.gif" border="0" width="8" height="121" vspace="220"><br/>
<img src="../../Images/FormImages/BarCodeLineStatement.gif" border="0" width="8" height="121"></div>
<div class="VerticalBarCodeMRN"><% =BarCodeMRN %></div>
<div class="VerticalBarCodeDocType">*U21*</div>
<div class="VerticalBarCodeAcctType"><% =BarCodeAcctType %></div>
<div class="VerticalBarCodeDate"><% =BarCodeDate %></div>
</div>
</div>
<font style="font-size: 12px;">CONTAINS PROTECTED HEALTH INFORMATION - HANDLE ACCORDING TO MSKCC POLICY</font>
<table width="650" border="0" cellspacing="0" cellpadding="0">
<tr >
<td class="FormOuterTableTopRow"> <table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
<tr >
<td width="50%" align="center" valign="middle" class="FormInnerRowRightBorder"><span class="blackBoldText"><img src="../../Images/FormImages/<%= institutionShortName%>_FormLogo.gif" width="90" alt="" border="0" align="left"><%= institutionName%><br>
Urology General Patient</span><br> </td>
<td width="50%" align="center" valign="bottom" > <table width="325" border="0" cellspacing="1" cellpadding="0" >
<tr>
<td width="65"><img src="../../Images/shim.gif" border="0" width="65" height="1"></td>
<td align="left" width="260"><img src="../../Images/shim.gif" border="0" width="260" height="1"></td>
</tr>
<tr>
<td align="right">
<% =patientMRNLabel %>
</td>
<td align="left"><strong>
<% =patientMRN %>
</strong>
<% =patientDOB %> </td>
</tr>
<tr>
<td colspan="1" align="right">
<% =patientNameLabel %>
</td>
<td colspan="1" align="left"><strong>
<% =patientLastName %>, <% =patientFirstName %> <% =patientMiddleName %>
</strong></td>
</tr>
<tr>
<td align="right" valign="top">
<% =patientAddressLabel %>
</td>
<td align="left" valign="top">
<% =patientAddress1 %>
<% =patientAddress2 %>
<% =patientCity %>
<% =patientState %>
<% =patientPostalCode %> </td>
</tr>
<tr>
<td colspan="2"><img src="../../Images/shim.gif" border="0" width="1" height="5"></td>
</tr>
<tr>
<td colspan="2" align="center" valign="bottom" class="blackBoldText">Patient
Identification</td>
</tr>
</table></td>
</tr>
</table></td>
</tr>
<tr>
<td height="20" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="11"><span class="blackBoldText">Date:
<% =apptClinicDate %>
<img src="../../Images/shim.gif" border="0" width="220" height="1">Physician:
<% =apptPhysicianName %>
</span></td>
</tr>
<tr bgcolor="#FFFFFF">
<td class="FormOuterTableRow"><table width="100%" border="0" cellpadding="1" cellspacing="0">
<tr>
<td colspan="2" align="left" valign="middle" class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="1" /><span class="blackBoldText">Category of Service</span></td>
</tr>
<tr>
<td width="23%" valign="top" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1" align="texttop" /> New Patient Encounter<br />
(CPT 99201-99205)</td>
<td width="77%" valign="middle" class="FormInnerRowBottomBorder"><img src="../../Images/shim.gif" border="0" width="4" height="1" />Use for patients who have not been see by anyone in your billing group in the last 3 years <strong>AND</strong><br />
<img src="../../Images/shim.gif" border="0" width="12" height="1" /><strong>-</strong>Are self referred (includes those referred by friend or patient)<br />
<img src="../../Images/shim.gif" border="0" width="12" height="1" /><strong>-</strong>Do not have physician asking for your advice/opinion (see PIF sheet or PAS info)<br />
<img src="../../Images/shim.gif" border="0" width="12" height="1" /><strong>-</strong>Are referred solely for management and/or treatment of aspect of care<br /> </td>
</tr>
<tr>
<td valign="top" align="center" class="FormInsideTableRegCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1" align="texttop" /> Office Consultation <br />
(CPT 99241- 99245)</td>
<td class="FormInnerRowBottomBorder"><table width="100%" cellpadding="0" cellspacing="0" border="0">
<tr>
<td ><img src="../../Images/shim.gif" border="0" width="4" height="1" />Office Consultation is requested by _________________________ MD/PA/NP for my advice & opinion<br />
<img src="../../Images/shim.gif" border="0" width="4" height="1" />regarding this patient’s ______________________________________________________</td>
</tr>
</table></td>
<!--<td class="FormInsideTableRegCell"><img src="../../Images/shim.gif" border="0" width="4" height="1">Office Consultation is requested by _________________________ MD/PA/NP for my advice & opinion<br />
<img src="../../Images/shim.gif" border="0" width="4" height="1">regarding this patient’s ______________________________________________________</td>-->
</tr>
<tr>
<td valign="top" align="center" class="FormInnerRowRightBorder"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1" align="texttop" /> Established Patient Visit<br />
(CPT 99212-99215)</td>
<td><img src="../../Images/shim.gif" border="0" width="4" height="1" />Use for patients who<br />
<img src="../../Images/shim.gif" border="0" width="12" height="1" /><strong>-</strong>Are seeing you for the first time for management or treatment (Not a consult) and have been seen<br />
<img src="../../Images/shim.gif" border="0" width="18" height="1" />by someone else in your billing group in the last 3 years<br />
<img src="../../Images/shim.gif" border="0" width="12" height="1" /><strong>-</strong>Are seeing you for follow-up care/visits </td>
</tr>
</table></td>
</tr>
<tr bgcolor="#FFFFFF" >
<td class="FormOuterTableRow"> <table align="center" border="0" width="100%" cellpadding="0" cellspacing="0">
<tr >
<td align="left" valign="top" height="16" class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="12">Chief
Complaint<br> <br> <br> <br> </td>
</tr>
</table></td>
</tr>
<tr bgcolor="#FFFFFF" >
<td class="FormOuterTableRow" height="180" valign="top"><img src="../../Images/shim.gif" border="0" width="4" height="12"><span class="blackBoldText">HPI</span>
<br/><br/><br/><br/><br/><br/><br/><br/><br/><br/><br/><br/><br/><br/><br/><br/><br/><br/><br/><br/><br/>
<span><img id="HpiSpacer" runat="server" src="../../Images/shim.gif" border="0" width="4" height="1">Cancer Diagnosis :
<img src="../../Images/shim.gif" border="0" width="75" height="8">Urology Issue :
<img src="../../Images/shim.gif" border="0" width="75" height="8">Dx Date :
<img src="../../Images/shim.gif" border="0" width="75" height="8">2002 TNM Stage: </td>
</tr>
<tr>
<td valign="top" class="FormOuterTableRow"><table width="650" border="0" cellspacing="0" cellpadding="0">
<tr>
<td width="335" class="FormInnerRowRightBorder"> <table width="325" border="0" cellspacing="0" cellpadding="2">
<tr>
<td colspan="3"><span class="blackBoldText">Medications</span>
<img src="../../Images/shim.gif" border="0" width="50" height="1">
<input name="DateLastGnRH" type="checkbox" id="DateLastGnRH" value="yes">
Unchanged Since Last Visit</td>
</tr>
<tr align="center">
<td width="195" class="FormInsideTableTopCell">Agent</td>
<td width="60" class="FormInsideTableTopCell">Dose</td>
<td width="70" class="FormInsideTableTopCell">Schedule</td>
</tr>
<tr>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td class="FormInnerRowRightBorder"> </td>
<td class="FormInnerRowRightBorder"> </td>
<td class="FormInnerRowRightBorder"> </td>
</tr>
</table> </td>
<td width="315"> <table width="315" border="0" cellspacing="0" cellpadding="2">
<tr>
<td colspan="2" class="FormInnerRowBottomBorder"><span class="blackBoldText">Allergies</span> <span>
<input name="DateLastGnRH2" type="checkbox" id="DateLastGnRH2" value="yes">
NKA
<input name="DateLastGnRH3" type="checkbox" id="DateLastGnRH3" value="yes">
Unchanged Since Last Visit</span></td>
</tr>
<tr align="center">
<td width="150" class="FormInsideTableRegCell">Allergen</td>
<td width="165" class="FormInnerRowBottomBorder">Reaction</td>
</tr>
<tr>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInnerRowBottomBorder"> </td>
</tr>
<tr>
<td class="FormInsideTableRegCell"> </td>
<td class="FormInnerRowBottomBorder"> </td>
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