Allscripts Diagnosis Master File

Allscripts Diagnosis Master File
Complete this request form when a new diagnosis code must be added to the system. All information is required unless otherwise noted and must be complete for this request to be honored. This form can also be used to request a change to an existing record by noting the information that is to be revised.
Diagnosis Code:
Diagnosis Description:
Effective Date

MonthDayYear
Termination Date

MonthDayYear
Submitted By:

First NameLast Name
Date:

MonthDayYear
Phone Number:

Area CodePhone Number
Fax:

Area CodePhone Number
E-mail:
Special Instructions:
Internal Use
Status:
Status Details:
Vision Request Completed By:

First NameLast Name
Date:

MonthDayYear
Enterprise Completed By:

First NameLast Name
Date:

MonthDayYear
Should be Empty: