Step 1 of 3, ERE: Prepare Report for Provider, Social Security

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ERE: Prepare Report for Provider

Destination Information
Review & Add Information
Confirmation

Enter Provider Information

Select the provider for whom this Consultative Exam is being prepared.

Reviewing Provider:

Enter Patient Information

Patient Name:

First

Middle

Last

Patient Date of Birth:

mm/dd/yyyy

Destination and Request Information

Please refer to your request letter or barcode to complete this information.

Select destination by: More Info

Site Code
State

Site Code:

State:

Destination:

User Resources