Xarelto Questionnaire

Xarelto Questionnaire

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Xarelto Questionnaire
  • 1
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  • 2
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  • 3
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  • 4
    If you answer 'yes' to this question, please stop filling out this form.
    • YES
    • NO
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  • 5
    If you do not know the exact date, a month and year must be given.
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  • 6
    Client must have stopped taking Xarelto near or on injury date..
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  • 7
    Injury must have occurred while using the drug Xarelto.
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  • 8
    If you don't know the exact date, you must include a month and year.
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  • 9
    Answer must be YES in order to proceed.
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  • 10
    Only the BRAND version qualifies the client to a claim
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  • 11
    Minimum hospital stay is 2 days. Must have hospital name and address
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  • 12
    2 Part Question
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  • 13
    What condition or reason did a doctor originally put you on the drug for?
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  • 14
    You must provide the Doctors full name and address
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  • 15
    You must include the FULL ADDRESS
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  • 16
    The patient will know this
    • YES
    • NO
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  • 17
    • Yes
    • No
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  • 18
    i.e., Warfarin, Heparin, Coumadin, Lovenox? Reminder: Answering YES to this question is adisqualification.
    • YES
    • NO
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  • 19
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  • 20
    Must include at least one doctor that treated client during injury period.
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  • 21
    If YES, please provide DECEASED FULL NAME and PRIMARY CONTACT for this claim
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  • 22
    Only information about THIS claim
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  • 23
    i.e., Disability, SSI, Medicare, EBT, etc. Please list all benefits received.
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  • 24
    • Yes
    • No
    • Not Sure
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  • 25
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  • 26
    REQUIRED
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  • Should be Empty:
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