Online Demonstration

Confirmation of Case Management Closure

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Employee Information
SSN	123-45-6789	Date of Injury	04/01/2003
DOB	02/05/1967	Sex	Male
Occupation	Construction Worker	County of Injury	Davidson County
Medical Information
Physician(s)
Enter the overseeing physician's information.
Title		License Number
Chiro		98765
First Name		Last Name
Jonathan		Sample
City		State
Cityville		Tennessee
Diagnosis Codes	Description	Procedure Codes	Description
847.0	Cervical Strain/Sprain	847.1	Thorax Strain/Sprain
838.0	Foot Dislocation	70450	CT Head
72196	MRI Hip	71250	CT Chest
Physical Therapy?	No
Case Management Information
Total weeks the Case Management was Open?		3
Date the Case was Closed?		05/05/2003
Total Cost of the Case Management?		$400.34
Medical Savings?		$500.45
How was it saved?
Checked	Negotiated provider/facility discount.
Indemnity Savings?		$600.45
How was it saved?
Checked	Coordinated modified duty.
Case Manager(s)	Primary Joe Manager	Secondary Judy Sample	Tertiary Jane Q Sample
Closure Code		67890
Return To Work (RTW) Date		07/07/2005

Online Demonstration