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<%@ Control Language="c#" AutoEventWireup="false" Codebehind="UroBladNP.ascx.cs" Inherits="Caisis.UI.Modules.Bladder.PaperForms.UroBladNP" TargetSchema="http://schemas.microsoft.com/intellisense/ie5"%>
<link href="../../../StyleSheets/formStyles.css" rel="stylesheet" type="text/css">
<div id="PaperFormStart">
<div align="left">
<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">*U07*</div>
<div class="VerticalBarCodeAcctType"><% =BarCodeAcctType %></div>
<div class="VerticalBarCodeDate"><% =BarCodeDate %></div>
</div>
</div>
<div align="center"><font style="font-size: 12px;">CONTAINS PROTECTED HEALTH INFORMATION - HANDLE ACCORDING TO <%= institutionShortName%> POLICY</font> </div>
<table width="700" 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 Bladder New 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 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 align="center" border="0" width="100%" cellpadding="2" cellspacing="0">
<tr>
<td width="325" height="35" align="left" class="FormInnerRowRightBorder"><img src="../../Images/shim.gif" border="0" width="4" height="0">Requesting M.D.:
<asp:Label ID="ReferringMd1Name" Runat="server" CssClass="blackBoldText" /><br>
<img src="../../Images/shim.gif" border="0" width="40" height="16"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="texttop">
<%= institutionShortName%> <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="texttop">
Non-<%= institutionShortName%></td>
<td width="325" align="left"><img src="../../Images/shim.gif" border="0" width="4" height="0">Requesting M.D.:
<asp:Label ID="ReferringMd2Name" Runat="server" CssClass="blackBoldText" /><br>
<img src="../../Images/shim.gif" border="0" width="40" height="16"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="texttop">
<%= institutionShortName%> <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="texttop">
Non-<%= institutionShortName%></td>
</tr>
<tr>
<td height="22" align="left" class="FormInnerRowRightBorder"><table width="300" border="0" cellspacing="0" cellpadding="1">
<tr>
<td width="70" align="right" valign="bottom">Phone</td>
<td class="FormInnerRowBottomBorder"> <asp:Label ID="ReferringMd1Phone" Runat="server" CssClass="blackBoldText" /></td>
</tr>
<tr>
<td align="right" valign="bottom">Fax</td>
<td class="FormInnerRowBottomBorder"> <asp:Label ID="ReferringMd1Fax" Runat="server" CssClass="blackBoldText" /></td>
</tr>
<tr>
<td align="right" valign="bottom">Specialty</td>
<td class="FormInnerRowBottomBorder"> <asp:Label ID="ReferringMd1Specialty" Runat="server" CssClass="blackBoldText" /></td>
</tr>
</table></td>
<td align="left"><table width="300" border="0" cellspacing="0" cellpadding="1">
<tr>
<td width="70" align="right" valign="bottom">Phone</td>
<td class="FormInnerRowBottomBorder"> <asp:Label ID="ReferringMd2Phone" Runat="server" CssClass="blackBoldText" /></td>
</tr>
<tr>
<td align="right" valign="bottom">Fax</td>
<td class="FormInnerRowBottomBorder"> <asp:Label ID="ReferringMd2Fax" Runat="server" CssClass="blackBoldText" /></td>
</tr>
<tr>
<td align="right" valign="bottom">Specialty</td>
<td class="FormInnerRowBottomBorder"> <asp:Label ID="ReferringMd2Specialty" Runat="server" CssClass="blackBoldText" /></td>
</tr>
</table></td>
</tr>
</table></td>
</tr>-->
--%> <tr>
<td class="FormOuterTableRow">
<table width="100%" border="0" cellpadding="0" cellspacing="0">
<tr>
<td colspan="2" align="left" valign="middle" class="FormInsideTableTopCell"><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="FormInsideTableLeftCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> New Patient Encounter<br />(CPT 99201-99205)</td>
<td width="77%" valign="middle" class="FormInsideTableRegCell"><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="FormInsideTableLeftCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> Office Consultation <br />(CPT 99241- 99245)</td>
<td class="FormInsideTableRegCell">
<table width="100%" cellpadding="0" cellspacing="0" border="0">
<tr>
<td class="FormInsideTableRegCell" colspan="2"><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抯 ______________________________________________________</td>
</tr>
<tr>
<td width="50%" height="35" align="left" class="FormInnerRowRightBorder"><img src="../../Images/shim.gif" border="0" width="4" height="0">Requesting M.D.: <asp:Label ID="ReferringMd1Name" Runat="server" CssClass="blackBoldText" /><br>
<img src="../../Images/shim.gif" border="0" width="40" height="16"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="texttop">
<%= institutionShortName%> <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="texttop">Non-<%= institutionShortName%></td>
<td width="50%" align="left"><img src="../../Images/shim.gif" border="0" width="4" height="0">Contact M.D.: <asp:Label ID="ReferringMd2Name" Runat="server" CssClass="blackBoldText" /><br>
<img src="../../Images/shim.gif" border="0" width="40" height="16"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="texttop">
<%= institutionShortName%> <img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" align="texttop"> Non-<%= institutionShortName%></td>
</tr>
<tr>
<td width="50%" class="FormInnerRowRightBorder">
<table width="100%" cellpadding="0" cellspacing="0" border="0">
<tr>
<td width="20%" align="right" valign="bottom">Phone</td>
<td width="80%" class="FormInnerRowBottomBorder"> <asp:Label ID="ReferringMd1Phone" Runat="server" CssClass="blackBoldText" /></td>
</tr>
<tr>
<td align="right" valign="bottom">Fax</td>
<td class="FormInnerRowBottomBorder"> <asp:Label ID="ReferringMd1Fax" Runat="server" CssClass="blackBoldText" /></td>
</tr>
<tr>
<td align="right" valign="bottom">Specialty</td>
<td class="FormInnerRowBottomBorder"> <asp:Label ID="ReferringMd1Specialty" Runat="server" CssClass="blackBoldText" /></td>
</tr>
</table>
</td>
<td width="50%">
<table width="100%" cellpadding="0" cellspacing="0" border="0">
<tr>
<td width="20%" align="right" valign="bottom">Phone</td>
<td width="80%" class="FormInnerRowBottomBorder"> <asp:Label ID="ReferringMd2Phone" Runat="server" CssClass="blackBoldText" /></td>
</tr>
<tr>
<td align="right" valign="bottom">Fax</td>
<td class="FormInnerRowBottomBorder"> <asp:Label ID="ReferringMd2Fax" Runat="server" CssClass="blackBoldText" /></td>
</tr>
<tr>
<td align="right" valign="bottom">Specialty</td>
<td class="FormInnerRowBottomBorder"> <asp:Label ID="ReferringMd2Specialty" Runat="server" CssClass="blackBoldText" /></td>
</tr>
</table>
</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抯 ______________________________________________________</td>-->
</tr>
<tr>
<td valign="top" align="center" class="FormInsideTableLeftCell"><img src="../../Images/FormImages/WinCheckbox.gif" width="13" height="13" vspace="1"> Established Patient Visit<br />(CPT 99212-99215)</td>
<td class="FormInsideTableRegCell"><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>
<!--Section commented out until new version approved: July 2006 Kevin-->
<!--<tr bgcolor="#FFFFFF" >
<td valign="top" class="FormOuterTableRow"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="4" height="12">Category of Service</span><br>
<table width="100%" border="0" cellspacing="0" cellpadding="4">
<tr valign="top">
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