Case Create Worksheet

 

SSN:

 


 

Check either # 1, #2 or # 3 and follow the instructions.

1.

Create Claim in both ECMS(B) and ECMS(E). Check either (a) or (b) below:

(a)

 

Enter ALL medical conditions claimed on the form (EE-1 or 2) in both ECMS (B) and (E)

 

(b)

Enter medical conditions in ECMS (B) and (E) as specified below:

 

 

Enter these conditions in ECMS - B

 

Enter these conditions in ECMS- E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Create Claim in ECMS(B) only Enter all claimed medical conditions only in ECMS(B)

 

3.

Create Claim in ECMS(E) only Enter all claimed medical conditions only in ECMS(E)

 

 

Reviewer:

 

 

 

 

 

 

 

Printed Name

 

Signature

 

Date

Case Creator:

 

 

 

 

 

 

Printed Name

 

Signature

 

Date