📄 urosexfuncnp.ascx
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<%@ Control Language="c#" AutoEventWireup="false" Codebehind="UroSexFuncNP.ascx.cs" Inherits="Caisis.UI.Modules.All.PaperForms.UroSexFuncNP" 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">*U15*</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 <%= institutionShortName%> POLICY</font>
<table width="650" border="0" cellspacing="0" cellpadding="0">
<tr>
<td class="FormOuterTableTopRow">
<table align="center" border="0" width="650" cellpadding="1" cellspacing="0">
<tr>
<td width="325" align="center" valign="middle" class="FormInnerRowRightBorder"><img src="../../Images/FormImages/<%= institutionShortName%>_FormLogo.gif" width="90" alt="" border="0" align="left"><span class="blackBoldText"><%= institutionName%><br>Urology Sexual Function New Patient<br></span></td>
<td width="325" 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 class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="15"><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>
<td class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/FormImages/shim.gif" border="0" width="4" height="15">Chief Complaint</span>
<table width="100%" cellpadding="0" cellspacing="0" border="0">
<tr>
<td class="FormInsideTableTopCell"><input type="checkbox" name="No242">Erectile Dysfunction</td>
<td class="FormInsideTableTopCell"><input type="checkbox" name="No242">Penile Curvature</td>
<td class="FormInsideTableTopCell"><input type="checkbox" name="No242">Ejaculation Problems</td>
<td class="FormInsideTableTopCell"><input type="checkbox" name="No242">Orgasm Problems</td>
</tr>
<tr>
<td class="FormInsideTableRegCell"><input type="checkbox" name="No242">Low Testosterone</td>
<td colspan="3" class="FormInsideTableRegCell"><input type="checkbox" name="No242">Other:</td>
</tr>
</table> </td>
</tr>
<tr>
<td class="FormOuterTableRow"><table align="center" border="0" width="100%" cellpadding="1" cellspacing="0">
<tr >
<td align="left" height="17"><img src="../../Images/shim.gif" border="0" width="4" height="0">Requesting M.D.:
<asp:Repeater ID="ReferringMD" runat=server >
<ItemTemplate>
<%# DataBinder.Eval(Container.DataItem, "phFirstName") %>
<%# DataBinder.Eval(Container.DataItem, "phLastName") %>
(
<%# DataBinder.Eval(Container.DataItem, "phInstitution") %>
)</ItemTemplate>
<SeparatorTemplate>, </SeparatorTemplate>
</asp:Repeater> <asp:Label ID="blankReferrringMD" Runat="server"></asp:Label> </td>
</tr>
<tr>
<td height="17" colspan="2" align="left" class="FormInnerRowNoBorder"><img src="../../Images/shim.gif" border="0" width="4" height="0">Requested
by: <img src="../../Images/FormImages/shim.gif" border="0" width="20" height="1">
<input type="checkbox" name="No22222">
Self <img src="../../Images/FormImages/shim.gif" border="0" width="20" height="1">
<input type="checkbox" name="No22232">
Friend<img src="../../Images/FormImages/shim.gif" border="0" width="20" height="1">
<input type="checkbox" name="No22252">
Other</td>
</tr>
</table></td>
</tr>
<tr>
<td class="FormOuterTableRow"><table width="650" border="0" cellspacing="0" cellpadding="1">
<tr>
<td class="FormInnerRowBottomBorder"><span class="blackBoldText">Demographics</span></td>
</tr>
<tr>
<td class="FormInnerRowBottomBorder">Age: __________<img src="../../Images/FormImages/shim.gif" border="0" width="50" height="1">Best
contact phone number: _______________________<br> <img src="../../Images/FormImages/shim.gif" border="0" width="1" height="11">Race:<img src="../../Images/FormImages/shim.gif" border="0" width="25" height="1">
<input type="checkbox" name="No222">
White <img src="../../Images/FormImages/shim.gif" border="0" width="15" height="1">
<input type="checkbox" name="No223">
African-American <img src="../../Images/FormImages/shim.gif" border="0" width="15" height="1">
<input type="checkbox" name="No224">
Asian <img src="../../Images/FormImages/shim.gif" border="0" width="15" height="1">
<input type="checkbox" name="No2242">
Hispanic<img src="../../Images/FormImages/shim.gif" border="0" width="15" height="1">
<input type="checkbox" name="No225">
Non-Hispanic<img src="../../Images/FormImages/shim.gif" border="0" width="15" height="1">
<input type="checkbox" name="No2252">
Other</td>
</tr>
<tr>
<td class="FormInnerRowBottomBorder" valign="middle"><img src="../../Images/FormImages/shim.gif" border="0" width="1" height="1">Sexual Orientation:
<img src="../../Images/FormImages/shim.gif" border="0" width="30" height="1"><input type="checkbox" name="No22">Heterosexual
<img src="../../Images/FormImages/shim.gif" border="0" width="18" height="1"><input type="checkbox" name="No23">Homosexual
<img src="../../Images/FormImages/shim.gif" border="0" width="18" height="1"><input type="checkbox" name="No24">Undefined</td>
</tr>
<tr>
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