1. Chart ID:
Code Chart Not Available
2013
(please check)
2014
(please check)
ALF
Chart located at assisted living facility
CIU Chart in use, not available after multiple
attempts
CML Chart at multiple locations, office unable
to provide chart at this location
HRO Hospital record only, no record at this
office
NTP
Office states this is not their patient
PID
Patient is deceased
PNS
Patient not seen by this office yet
SOF Chart not on location, stored at offsite
facility
UID Unable to identify patient, due to
incorrect date of birth
UTL
Office unable to locate chart
Code No Patient Visits
2013
(please check)
2014
(please check)
NPV
Patient has never been seen by
provider during DOS period
Office contact name:
Office contact signature:
Date:
HCC Medicare Risk Adjustment Review
Chart Not Available/No Patient Visit Checklist
Please indicate which reason the chart is not available
CNA/NPV:
05/07/2014
SubmitPrint
CNA
