Miscellaneous Note
Patient Name
First Name
Last Name
Type of provider
*
Medical Provider
Counseling Provider
TCM Provider
Staff
Medical Provider
Please Select
Guy M. Lerner, MD
Leslie M. Dally, DO
Erika Ruth, MD
Tara O'Brien, APRN
Don Zinno, APRN
Craig Rouben, APRN
Brandi Thomas, APRN, PMHNP
Monica Taylor, APRN, PMHNP
Javier Suarez Rivera, APRN
Staff
Please Select
Barb
Adam
Antwanette
Liz
AJ
Cara
Tammy
Counseling Provider
Please Select
Lena Kline, LPCC-S
Darlena Smith, LCSW
Laura Kruthoffer, LPCC
Camille Phillips, CSW
TCM Provider
Please Select
Kevin Johnson, MEd
Melody Ognan, BS
Ayiana Ognan, BA
James Spencer, BA
Amanda Monroe, BS
Robin Flowers, BA
Dustin Floyd, BS
UniqueID
*
Note created on this date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of note
UniqueID_DOS
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Miscellaneous Note
As the provider, I attest that I provided services for this patient, and this is my electronic signature
Today's Provider
DATE OF SERVICE
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: