Xarelto Questionnaire

Xarelto Questionnaire

Xarelto Torte Questions Form Preview
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Xarelto Questionnaire
Xarelto Torte Questions
  • 1
    Email associated with client card directly (make HYPERLINK) (If you do not know this you can move on)
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  • 2
    If deceased SOL is 2 years from TODAY
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  • 3
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  • 4
    SOL is 2 years, SKIP IF ALIVE
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  • 5
    If YES, please provide CLIENTS FULL NAME that has POA. SKIP IF ALIVE
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  • 6
    VERIFY ADDRESS
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  • 7
    If client does not have an email use:  No-Email@google.com
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  • 8
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  • 9
    If you answer 'yes' to this question, please stop filling out this form.
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  • 10
    If still taking Xarelto, DISQUALIFIED. SOL is 2007+
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  • 11
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  • 12
    Please describe the "OTHER" answer from Previous Question
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  • 13
    If you do not know the exact date, a MONTH & YEAR MUST be given. (Month/Day/Year)
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  • 14
    If you don't know the exact date, you MUST include a MONTH & YEAR (Month/Day/Year)
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  • 15
    (If NO, client is DISQUALIFIED)
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  • 16
    Only the BRAND version qualifies the client to a claim
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  • 17
    Minimum hospital stay is 2 days. Must have hospital name and address
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  • 18
    3 Part Question
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  • 19
    You must provide the Doctors full name and address (NO HYPERLINKS)
    Created with Sketch.
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  • 28
    i.e., Disability, SSI, Medicare, EBT, etc. Please list all benefits received.
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  • 29
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  • 30
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  • 31
    REQUIRED (Month/Day/Year)
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  • 32
    Just click YES to submit
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  • Should be Empty:
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