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<td align="left" style="font-size:18px"><strong>Start of Care</strong></td>
<td align="right" style="font-size:18px"><strong><cfoutput query="GetProviderName">#ProviderName#</cfoutput></strong></td>
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<td align="left" style="font-size:20px">Page <strong><cfoutput>#cfdocument.currentpagenumber#</cfoutput></strong> of <strong><cfoutput>#cfdocument.totalpagecount#</cfoutput></strong> </td>
<td align="right" style="font-size:20px">© Copyright: Tb solutions.</td>
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<th width="94%" align="center" valign="bottom"><h3><strong>TRACKING SHEET</strong> </h3></th>
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<td width="1%"><table width="100%" border="0" cellspacing="0" cellpadding="0">
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<td height="15" colspan="4" style="padding-left:4px"> </td>
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<td height="20" colspan="4" style="padding-left:4px"><strong>(010) CMS Certification Number:</strong> <cfoutput>#trim(FORM.010_CCN)#</cfoutput> (485 No.5)</td>
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<td height="20" colspan="2" style="padding-left:4px"><strong>(014) Branch State:</strong> <cfoutput>#trim(FORM.014_BRANCH_STATE)#</cfoutput></td>
<td colspan="2" style="padding-left:4px"><strong>(016) Branch ID Number:</strong> <cfoutput>#trim(FORM.016_BRANCH_ID)#</cfoutput></td>
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<tr style="font-size:12px">
<td height="20" colspan="4" style="padding-left:4px"><strong>Attending physician's name</strong> who will sign the Plan of Care: <cfoutput>#trim(FORM.PhysicianName)#</cfoutput></td>
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<td height="20" colspan="4" style="padding-left:4px"> </td>
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<td height="20" colspan="3" style="padding-left:4px"><strong>(018) National Provider Identifier (NPI)</strong> for the attending physician who has signed the plan of care: <cfoutput>#trim(FORM.018_PHYSICIAN_ID)#</cfoutput></td>
<td height="20" style="padding-left:4px"><input name="018_PHYSICIAN_UK" type="checkbox" id="018_PHYSICIAN_UK" <cfif IsDefined("FORM.018_PHYSICIAN_UK") AND #FORM.018_PHYSICIAN_UK# EQ '1'>checked="checked" </cfif> />
<strong>NA - Not Applicable</strong></td>
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<tr style="font-size:12px">
<td height="20" colspan="4" style="padding-left:4px"><strong>(020) Patient ID Number:</strong> <cfoutput>#trim(FORM.020_PAT_ID)#</cfoutput></td>
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<tr style="font-size:12px">
<td height="20" colspan="2" style="padding-left:4px"><strong>(030) Start of Care:</strong> <cfoutput>#DateFormat(FORM.030_START_CARE_DT, 'mm/dd/yyyy')#</cfoutput> (485 No.2)</td>
<td width="450" height="20" style="padding-left:4px"><strong>(032) Resumption of Care Date:</strong>
<cfif IsDefined("FORM.032_ROC_DT") AND #FORM.032_ROC_DT# NEQ ''>
<cfoutput>#DateFormat(FORM.032_ROC_DT, 'mm/dd/yyyy')#</cfoutput>
</cfif></td>
<td width="259" style="padding-left:4px"><input name="032_ROC_DT_NA" type="checkbox" id="032_ROC_DT_NA" <cfif IsDefined("FORM.032_ROC_DT_NA") AND #FORM.032_ROC_DT_NA# EQ '1'>checked="checked" </cfif> />
<strong>NA - Not Applicable</strong></td>
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<td height="20" colspan="2" style="padding-left:4px"> </td>
<td height="20" style="padding-left:4px"> </td>
<td style="padding-left:4px"> </td>
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<td height="20" colspan="4" style="padding-left:4px"><strong>(040) Patient Name:</strong> (485 No.6)</td>
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<tr style="font-size:12px">
<td width="371" height="20" style="padding-left:4px">First Name: <cfoutput>#FORM.040_PAT_FNAME#</cfoutput></td>
<td width="299" style="padding-left:4px">(MI) : <cfoutput>#FORM.040_PAT_MI#</cfoutput></td>
<td height="20" style="padding-left:4px">Last Name: <cfoutput>#FORM.040_PAT_LNAME#</cfoutput></td>
<td height="20" style="padding-left:4px">Suffix: <cfoutput>#FORM.040_PAT_SUFFIX#</cfoutput></td>
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<tr style="font-size:12px">
<td height="20" colspan="4" style="padding-left:4px">Patient Address: <cfoutput>#FORM.Patient_Address#</cfoutput></td>
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<td height="20" colspan="4" style="padding-left:4px">City: <cfoutput>#FORM.Patient_City#</cfoutput></td>
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<td height="20" colspan="2" style="padding-left:4px"><strong>(050) Patient State of Residence:</strong> <cfoutput>#FORM.050_PAT_ST#</cfoutput></td>
<td height="20" colspan="2" style="padding-left:4px"><strong>(060) Patient Zip Code:</strong> <cfoutput>#FORM.060_PAT_ZIP#</cfoutput></td>
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<tr style="font-size:12px">
<td height="20" colspan="4" style="padding-left:4px"> </td>
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<td height="20" colspan="2" style="padding-left:4px"><strong>(063) Medicare Number:</strong> <cfoutput>#FORM.063_MEDICARE_NUM#</cfoutput> (485 No.1)</td>
<td height="20" style="padding-left:4px"><input name="063_MEDICARE_NA" type="checkbox" id="063_MEDICARE_NA" <cfif IsDefined("FORM.063_MEDICARE_NA") AND #FORM.063_MEDICARE_NA# EQ '1'>checked="checked" </cfif> />
<strong>NA - Not Applicable</strong></td>
<td height="20" style="padding-left:4px"> </td>
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<tr style="font-size:12px">
<td height="20" colspan="2" style="padding-left:4px"><strong>(064) Social Security Number:</strong> <cfoutput>#FORM.064_SSN#</cfoutput></td>
<td height="20" style="padding-left:4px"><input name="064_SSN_UK" type="checkbox" id="064_SSN_UK" <cfif IsDefined("FORM.064_SSN_UK") AND #FORM.064_SSN_UK# EQ '1'>checked="checked" </cfif> />
<strong>UK - Unknown or Not Available</strong></td>
<td height="20" style="padding-left:4px"> </td>
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<tr style="font-size:12px">
<td height="20" colspan="2" style="padding-left:4px"><strong>(065) Medicaid Number:</strong> <cfoutput>#FORM.065_MEDICAID_NUM#</cfoutput></td>
<td height="20" style="padding-left:4px"><input name="065_MEDICAID_NA" type="checkbox" id="065_MEDICAID_NA" <cfif IsDefined("FORM.065_MEDICAID_NA") AND #FORM.065_MEDICAID_NA# EQ '1'>checked="checked" </cfif> />
<strong>NA -Not Medicaid</strong></td>
<td height="20" style="padding-left:4px"> </td>
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<tr style="font-size:12px">
<td height="20" colspan="2" style="padding-left:4px"><strong>(066) Birth Date:</strong> <cfoutput>#DateFormat(FORM.066_PAT_BIRTH_DT, 'mm/dd/yyyy')#</cfoutput> (485 No.8)</td>
<td height="20" style="padding-left:4px"> </td>
<td height="20" style="padding-left:4px"> </td>
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<tr style="font-size:12px">
<td height="20" colspan="2" style="padding-left:4px"> </td>
<td height="20" style="padding-left:4px"> </td>
<td height="20" style="padding-left:4px"> </td>
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<tr style="font-size:12px">
<td height="20" colspan="2" style="padding-left:4px"><strong>(069) Gender:</strong>
<input name="069_PAT_GENDER" type="radio" id="069_PAT_GENDER" <cfif IsDefined("FORM.069_PAT_GENDER") AND #FORM.069_PAT_GENDER# EQ '1'>checked="checked" </cfif> />Male
<input name="069_PAT_GENDER" type="radio" id="069_PAT_GENDER" <cfif IsDefined("FORM.069_PAT_GENDER") AND #FORM.069_PAT_GENDER# EQ '2'>checked="checked" </cfif> />Female </td>
<td height="20" colspan="2" style="padding-left:4px">Marital Status:
<cfif IsDefined("FORM.Marital_Status") AND #FORM.Marital_Status# NEQ ''>
<cfoutput>#FORM.Marital_Status#</cfoutput>
</cfif>
</td>
</tr>
</table></td>
</tr>
</table>
<!---I WANT THE PAGE NUMBER COMES HERE--->
<B>I WANT THE PAGE NUMBER COMES HERE</B><P>
<table width="100%" border="0" cellpadding="0" cellspacing="0" style="border-right-width:thin; border-right-color:#CCC; border-right-style:solid; border-right-width:thin; border-bottom-width:thin; border-bottom-color:#CCC; border-bottom-style:solid; border-left-width:thin; border-left-color:#CCC; border-left-style:solid">
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<td width="1%"><table width="100%" border="0" cellspacing="0" cellpadding="0">
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<td height="15" colspan="2" valign="bottom" style="padding-left:4px"> </td>
<td colspan="2" valign="bottom" style="padding-left:4px"> </td>
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<td height="15" colspan="2" valign="bottom" style="padding-left:4px"><strong>(140) Race/Ethnicity: (Mark all that apply)</strong></td>
<td colspan="2" valign="bottom" style="padding-left:4px"><strong>(150) Current payment sources for Home Care: (Mark all that apply)</strong></td>
</tr>
<tr style="font-size:12px">
<td height="15" colspan="2" valign="bottom" style="padding-left:4px"><input name="140_Native_American" type="checkbox" id="140_Native_American" <cfif IsDefined("FORM.140_Native_American") AND #FORM.140_Native_American# EQ '1'>checked="checked" </cfif> />
1 - American Indian or Alaska Native</td>
<td colspan="2" valign="bottom" style="padding-left:4px"><input name="150_CPAY0" type="checkbox" id="150_CPAY0" <cfif IsDefined("FORM.150_CPAY0") AND #FORM.150_CPAY0# EQ '1'>checked="checked" </cfif> />
0 - None; no charge for current services</td>
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<tr style="font-size:12px">
<td height="15" colspan="2" valign="bottom" style="padding-left:4px"><input name="140_Asian" type="checkbox" id="140_Asian" <cfif IsDefined("FORM.140_Asian") AND #FORM.140_Asian# EQ '1'>checked="checked" </cfif> />
2 - Asian</td>
<td colspan="2" valign="bottom" style="padding-left:4px"><input name="150_CPAY1" type="checkbox" id="150_CPAY1" <cfif IsDefined("FORM.150_CPAY1") AND #FORM.150_CPAY1# EQ '1'>checked="checked" </cfif> />
1 - Medicare (traditional fee-for-service)</td>
</tr>
<tr style="font-size:12px">
<td height="15" colspan="2" valign="bottom" style="padding-left:4px"><input name="140_Black" type="checkbox" id="140_Black" <cfif IsDefined("FORM.140_Black") AND #FORM.140_Black# EQ '1'>checked="checked" </cfif> />
3 - Black or African American</td>
<td colspan="2" valign="bottom" style="padding-left:4px"><input name="150_CPAY2" type="checkbox" id="150_CPAY2" <cfif IsDefined("FORM.150_CPAY2") AND #FORM.150_CPAY2# EQ '1'>checked="checked" </cfif> />
2 - Medicare (HMO/managed care, Advantage Plan)</td>
</tr>
<tr style="font-size:12px">
<td height="15" colspan="2" valign="bottom" style="padding-left:4px"><input name="140_Latino" type="checkbox" id="140_Latino" <cfif IsDefined("FORM.140_Latino") AND #FORM.140_Latino# EQ '1'>checked="checked" </cfif> />
4 - Hispanic or Latino</td>
<td colspan="2" valign="bottom" style="padding-left:4px"><input name="150_CPAY3" type="checkbox" id="150_CPAY3" <cfif IsDefined("FORM.150_CPAY3") AND #FORM.150_CPAY3# EQ '1'>checked="checked" </cfif> />
3 - Medicaid (traditional fee-for-service)</td>
</tr>
<tr style="font-size:12px">
<td height="15" colspan="2" valign="bottom" style="padding-left:4px"><input name="140_PIslander" type="checkbox" id="140_PIslander" <cfif IsDefined("FORM.140_PIslander") AND #FORM.140_PIslander# EQ '1'>checked="checked" </cfif> />
5 - Native Hawaiian or Pacific Islander</td>
<td colspan="2" valign="bottom" style="padding-left:4px"><input name="150_CPAY4" type="checkbox" id="150_CPAY4" <cfif IsDefined("FORM.150_CPAY4") AND #FORM.150_CPAY4# EQ '1'>checked="checked" </cfif> />
4 - Medicaid (HMO/managed care)</td>
</tr>
<tr style="font-size:12px">
<td height="15" colspan="2" valign="bottom" style="padding-left:4px"><input name="140_White" type="checkbox" id="140_White" <cfif IsDefined("FORM.140_White") AND #FORM.140_White# EQ '1'>checked="checked" </cfif> />
6 - White</td>
<td colspan="2" valign="bottom" style="padding-left:4px"><input name="150_CPAY5" type="checkbox" id="150_CPAY5" <cfif IsDefined("FORM.150_CPAY5") AND #FORM.150_CPAY5# EQ '1'>checked="checked" </cfif> />
5 - Worker's Compensation</td>
</tr>
<tr style="font-size:12px">
<td height="15" colspan="2" valign="bottom" style="padding-left:4px"> </td>
<td colspan="2" valign="bottom" style="padding-left:4px"><input name="150_CPAY6" type="checkbox" id="150_CPAY6" <cfif IsDefined("FORM.150_CPAY6") AND #FORM.150_CPAY6# EQ '1'>checked="checked" </cfif> />
6 - Title Programs(e.g, TItle III,V or XX) </td>
</tr>
<tr style="font-size:12px">
<td height="15" colspan="2" valign="bottom" style="padding-left:4px"> </td>
<td colspan="2" valign="bottom" style="padding-left:4px"><input name="150_CPAY7" type="checkbox" id="150_CPAY7" <cfif IsDefined("FORM.150_CPAY7") AND #FORM.150_CPAY7# EQ '1'>checked="checked" </cfif> />
7 - Other Government(e.g, CHAMPUS, VA, etc.) </td>
</tr>
<tr style="font-size:12px">
<td height="15" colspan="2" valign="bottom" style="padding-left:4px"> </td>
<td colspan="2" valign="bottom" style="padding-left:4px"><input name="150_CPAY8" type="checkbox" id="150_CPAY8" <cfif IsDefined("FORM.150_CPAY8") AND #FORM.150_CPAY8# EQ '1'>checked="checked" </cfif> />
8 - Private Insurance</td>
</tr>
<tr style="font-size:12px">
<td height="15" colspan="2" valign="bottom" style="padding-left:4px"> </td>
<td colspan="2" valign="bottom" style="padding-left:4px"><input name="150_CPAY9" type="checkbox" id="150_CPAY9" <cfif IsDefined("FORM.150_CPAY9") AND #FORM.150_CPAY9# EQ '1'>checked="checked" </cfif> />
9 - Private HMO/Managed Care</td>
</tr>
<tr style="font-size:12px">
<td height="15" colspan="2" valign="bottom" style="padding-left:4px"> </td>
<td colspan="2" valign="bottom" style="padding-left:4px"><input name="150_CPAY10" type="checkbox" id="150_CPAY10" <cfif IsDefined("FORM.150_CPAY10") AND #FORM.150_CPAY10# EQ '1'>checked="checked" </cfif> />
10 - Self pay</td>
</tr>
<tr style="font-size:12px">
<td height="15" colspan="2" valign="bottom" style="padding-left:4px"> </td>
<td colspan="2" valign="bottom" style="padding-left:4px"><input name="150_CPAY11" type="checkbox" id="150_CPAY11" <cfif IsDefined("FORM.150_CPAY11") AND #FORM.150_CPAY11# EQ '1'>checked="checked" </cfif> />
11 - Other (Specify)
<cfif IsDefined("FORM.150_CPAY_OTHER") AND #FORM.150_CPAY_OTHER# NEQ ''>
<cfoutput>#FORM.150_CPAY_OTHER#</cfoutput>
</cfif>
</td>
</tr>
<tr style="font-size:12px">
<td height="15" colspan="2" valign="bottom" style="padding-left:4px"> </td>
<td colspan="2" valign="bottom" style="padding-left:4px"><input name="150_CPAY12_UK" type="checkbox" id="150_CPAY12_UK" <cfif IsDefined("FORM.150_CPAY12_UK") AND #FORM.150_CPAY12_UK# EQ '1'>checked="checked" </cfif> />
UK - Unknown</td>
</tr>
<tr style="font-size:12px">
<td height="15" colspan="2" valign="bottom" style="padding-left:4px"> </td>
<td colspan="2" valign="bottom" style="padding-left:4px"> </td>
</tr>
<tr style="font-size:12px">
<td height="15" colspan="2" valign="bottom" style="padding-left:4px"> </td>
<td colspan="2" valign="bottom" style="padding-left:4px"> </td>
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<tr style="font-size:12px">
<td width="27%" height="15" valign="bottom" style="padding-left:4px">Signature/Title of discipline completing:</td>
<td width="21%" valign="bottom" style="padding-left:4px"><cfoutput>#FORM.DISCIPLINE_COMPLETED#</cfoutput></td>
<td width="8%" align="right" valign="bottom" style="padding-left:4px">Date: </td>
<td width="44%" valign="bottom" style="padding-left:4px"><cfoutput>#DateFormat(FORM.DISCIPLINE_COMPLETED_DT, 'mm/dd/yyyy')#</cfoutput></td>
</tr>
<tr style="font-size:12px">
<td height="15" colspan="2" valign="bottom" style="padding-left:4px"> </td>
<td colspan="2" valign="bottom" style="padding-left:4px"> </td>
</tr>
<tr style="font-size:12px">
<td height="15" valign="bottom" style="padding-left:4px">Signature/Title of discipline revisign</td>
<td height="15" valign="bottom" style="padding-left:4px"><cfoutput>#FORM.DISCIPLINE_REVISING#</cfoutput></td>
<td align="right" valign="bottom" style="padding-left:4px">Date: </td>
<td valign="bottom" style="padding-left:4px"><cfoutput>#DateFormat(FORM.DISCIPLINE_REVISING_DT, 'mm/dd/yyyy')#</cfoutput></td>
</tr>
<tr style="font-size:12px">
<td height="15" colspan="2" valign="bottom" style="padding-left:4px"> </td>
<td colspan="2" valign="bottom" style="padding-left:4px"> </td>
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