28. Modification of the agreement on forms for statutory health care

from April 1, 1995

1. The following changes have been made to the agreement on forms for statutory health care:

1.1. Number 2.5 is changed as follows:

2.5 Sample 5: Billing slip for outpatient treatment, documentary evidence of medical treatment, clarification of somatic causes before starting psychotherapy, recognized psychotherapy (status: 4.2011)

1.2. Numbers 2.6 and 2.6.1 are changed as follows:

2.6 Sample 6: Transfer slip (as of: 4.2011)

2.6.1 The attached specimen 6 is the transfer slip to use.

1.3. Numbers 2.63 and 2.63.3 are changed as follows:

2.63 Model 63: Ordinance on Specialized Outpatient Palliative Care (SAPV) (Status: 4.2011)

2.63.3 For the surface printing of the pattern 63a is to use green color for both the front and the back, for the patterns 63b and 63c red color is to be used as the surface printing on the front side. Pattern 63d is not printed in color. The patterns 63b, 63c and 63d are unprinted on the reverse. No. 1.1.5 applies accordingly. The set of forms is in A4 format.

1.4. Numbers 2.71 to 2.71A.4 are deleted.

1.5. The note "2.72 to 2.79 unoccupied" is changed to:

2.71

to unoccupied

2.79

1.6. The number 2.80 is changed as follows:

2.80 Model 80: Documentation of the treatment entitlement of persons insured abroad (status: 4.2011)

1.7. Numbers 2.85, 2.85.1 and 2.85.2 are newly inserted as follows:

2.85 Model 85: Proof of entitlement if the claim is suspended in accordance with Section 16 (3a) SGB V (status: 4.2011 )

2.85.1 The health insurance funds must use sample 85 to prove eligibility when the claim is suspended in accordance with Section 16 (3a) SGB V.

2.85.2 For sample 85 white paper is used, the imprint is in black letters. The form is in the DIN A6 landscape format. The health insurance companies can embed the form in letter.

The table of contents changes accordingly.

2. The following changes will be made to the explanations of the forms:

2.1.Sample 6: Referral slip

The text is replaced by the following:

The referral slip is used to transfer the necessary diagnostic or therapeutic services to person another contract doctor, an institution approved in accordance with Section 311, Paragraph 2, Clauses 1 and 2 SGB V, medical care center, an authorized doctor or an authorized, medically-managed institution. A referral slip must also be used if the contracted doctor arranges an outpatient operation in the hospital or an outpatient treatment in the hospital in accordance with Section 116b SGB V. Medical services that are provided as part of the program for the early detection of breast cancer through mammography screening do not require referral to sample 6.

A referral slip may only be issued if the referring contract doctor has valid health insurance card in the quarter in question or valid proof of entitlement has been presented. Exceptions are permitted if, for example, B. the measures to be taken are urgently required or the referring contract doctor knows beyond doubt the health insurance provider.

The doctor who acts on the referral is generally bound by the referral slip issued; He is not allowed to issue his own billing slip (form 5).

The health insurances inform their insured that the referral slip issued by the referring contract doctor must be presented to the doctor who is called upon to make referral .

To be filled in by the referring contract doctor and to be observed by the doctor who acts on the referral:

1. The referring contract doctor must indicate whether the Referral for curative care, for prevention, for treatment according to § 116b SGB V (if known) or for the consultation of doctor with attending physician Treatment takes place.

2. The quarter in which the referral was issued is to be entered in the relevant field in the form "QJJ".

If the doctor acting on the referral begins his Treatment only in the following quarter, can use the issued referral slip t, provided the insured person can present valid health insurance card at the time of treatment. If the date up to which the KVK was valid has passed and there is no personal doctor-patient contact, new referral based on valid KVK must be issued in the following quarter.

3. For services according to Section 31.2, this is Enter the date of the operation in the form "DDMMYY".

4. The gender of the patient must be indicated by marking the relevant field.

The text is replaced by the following:

The referral slip is used to transfer the necessary diagnostic or therapeutic services to person another contract doctor, an institution approved in accordance with Section 311, Paragraph 2, Clauses 1 and 2 SGB V, medical care center, an authorized doctor or an authorized, medically-managed institution. A referral slip must also be used if the contracted doctor arranges an outpatient operation in the hospital or an outpatient treatment in the hospital in accordance with Section 116b SGB V. Medical services that are provided as part of the program for the early detection of breast cancer through mammography screening do not require referral to sample 6.

A referral slip may only be issued if the referring contract doctor has valid health insurance card in the quarter in question or valid proof of entitlement has been presented. Exceptions are permitted if, for example, B. the measures to be taken are urgently required or the referring contract doctor knows beyond doubt the health insurance provider.

The doctor who acts on the referral is generally bound by the referral slip issued; He is not allowed to issue his own billing slip (form 5).

The health insurances inform their insured that the referral slip issued by the referring contract doctor must be presented to the doctor who is called upon to make referral .

To be filled in by the referring contract doctor and to be observed by the doctor who acts on the referral:

1. The referring contract doctor must indicate whether the Referral for curative care, for prevention, for treatment according to § 116b SGB V (if known) or for the consultation of doctor with attending physician Treatment takes place.

2. The quarter in which the referral was issued is to be entered in the relevant field in the form "QJJ".

If the doctor acting on the referral begins his Treatment only in the following quarter, can use the issued referral slip t, provided the insured person can present valid health insurance card at the time of treatment. If the date up to which the KVK was valid has passed and there is no personal doctor-patient contact, new referral based on valid KVK must be issued in the following quarter.

3. For services according to Section 31.2, this is Enter the date of the operation in the form "DDMMYY".

4. The gender of the patient must be indicated by marking the relevant field.

The form must not be used for accidents at work, occupational diseases and school accidents. The settlement of the treatment of the accident or the consequences of the accident must be made with the accident insurance institution (on form A13 according to the doctor / accident insurance institution agreement). School accidents also include accidents of children in kindergartens and of students during their studies.

6. If the referring contract doctor has certified an incapacity for work, he informs the doctor who acts on the referral by stating the expected end indicates the inability to work in the field "AU bis". This information is only required if the management of the treatment is to be passed on to the doctor providing further treatment.

7. In the line “Referral to. . . “, with regard to the insured person's right to choose, no specific doctor needs to be specified, only the relevant area description (e.g. ophthalmology) must be entered. Exceptions to this rule are referrals to an authorized doctor or to an authorized, medically-managed institution for the implementation of certain examination or treatment methods (Section 24 (5) Federal Shell Agreement - Doctors). In these cases, the name and address of the authorized person can be given.

8. It must be checked in each case whether the transfer is for the execution of contract services for the consultation or for co- / further processing .

The type and scope of the orders must be specifically determined (specification of the fee schedule item or the precise service description). The doctor executing the order may only perform the services specified under "Order". An extension of the order according to type or scope requires the consent of the contract doctor who placed the order; it must be noted on the form.

With the referral for the consultant examination , diagnostic services are initiated, the type and scope of which the performing doctor decides. Enter the reason for the investigation. The performing doctor is free to choose his diagnostic steps. These measures should be completed within reasonable period and the referring doctor should be informed of the result as soon as possible. Therapeutic measures are not billable.

9.The referring contract doctor informs the doctor who acts on the referral by ticking the accident field if the treatment is necessary due to or as result of an accident so that the health insurance companies can claim costs from third parties. If the accident field is not ticked in the event of an accident, it means an unnecessary financial burden on the statutory health insurance provider.

The form must not be used for accidents at work, occupational diseases and school accidents. The settlement of the treatment of the accident or the consequences of the accident must be made with the accident insurance institution (on form A13 according to the doctor / accident insurance institution agreement). School accidents also include accidents of children in kindergartens and of students during their studies.

6. If the referring contract doctor has certified an incapacity for work, he informs the doctor who acts on the referral by stating the expected end indicates the inability to work in the field "AU bis". This information is only required if the management of the treatment is to be passed on to the doctor providing further treatment.

7. In the line “Referral to. . . “, with regard to the insured person's right to choose, no specific doctor needs to be specified, only the relevant area description (e.g. ophthalmology) must be entered. Exceptions to this rule are referrals to an authorized doctor or to an authorized, medically-managed institution for the implementation of certain examination or treatment methods (Section 24 (5) Federal Shell Agreement - Doctors). In these cases, the name and address of the authorized person can be given.

8. It must be checked in each case whether the transfer is for the execution of contract services for the consultation or for co- / further processing .

The type and scope of the orders must be specifically determined (specification of the fee schedule item or the precise service description). The doctor executing the order may only perform the services specified under "Order". An extension of the order according to type or scope requires the consent of the contract doctor who placed the order; it must be noted on the form.

With the referral for the consultant examination , diagnostic services are initiated, the type and scope of which the performing doctor decides. Enter the reason for the investigation. The performing doctor is free to choose his diagnostic steps. These measures should be completed within reasonable period and the referring doctor should be informed of the result as soon as possible. Therapeutic measures are not billable.

9.The referral for co-treatment is made to accompany or supplement diagnostic or therapeutic measures. In the event of further treatment, the entire diagnostic and therapeutic work is transferred to another doctor. The field "Co-treatment / further treatment" must also be ticked for referrals to carry out outpatient operations.

10. For patients with limited entitlement to benefits in accordance with Section 16 (3a) SGB V the referring contract doctor has to tick the corresponding field in order to inform the doctor who acts on the referral about the limited entitlement to benefits.

11. Under "Diagnosis / suspected diagnosis", " Findings / Medication " or " Order " must be provided by the referring contract doctor in order to give the doctor who acts on the referral information about his actions and unnecessary costs due to multiple examinations to avoid. For this reason, the contract doctor who is also treating / continuing treatment should be informed about the findings and / or treatment measures that have been collected so far.

To be completed by the doctor who acts on the referral:

12. The doctor performing contract service is entitled to have parts of this contract that he cannot perform himself performed by another doctor as contract service by "referral" . If it is not possible for the doctor who has acted on referral to carry out consultant examination without consulting further doctor, the doctor who carries out the consultant examination can have individual services performed by another doctor as contract services.

13. If the doctor, who has acted on referral, treats an accident that only occurred during his treatment or only became known during his treatment, he also ticks the accident field.

2.2. Sample 30: Health examination report form

The following point has been added:

3. The documentation can optionally be provided with the same content in electronic form in the Documentation by the doctor.

2.3. Sample 40: Documentation form for early cancer detection examinations for men

The following sentence is added:

The documentation can optionally be included in the documentation in electronic form with the same content by the doctor.

2.4. Samples 71 and 71A are deleted.

2.5. The note "Samples 72 to 79 unoccupied " is changed to:

"Samples 71 to 79 unoccupied".

2.6. The note "Samples 82 to 98 unoccupied" is changed to:

" Samples 82 to 84 unoccupied ”.The referral for co-treatment is made to accompany or supplement diagnostic or therapeutic measures. In the event of further treatment, the entire diagnostic and therapeutic work is transferred to another doctor. The field "Co-treatment / further treatment" must also be ticked for referrals to carry out outpatient operations.

10. For patients with limited entitlement to benefits in accordance with Section 16 (3a) SGB V the referring contract doctor has to tick the corresponding field in order to inform the doctor who acts on the referral about the limited entitlement to benefits.

11. Under "Diagnosis / suspected diagnosis", " Findings / Medication " or " Order " must be provided by the referring contract doctor in order to give the doctor who acts on the referral information about his actions and unnecessary costs due to multiple examinations to avoid. For this reason, the contract doctor who is also treating / continuing treatment should be informed about the findings and / or treatment measures that have been collected so far.

To be completed by the doctor who acts on the referral:

12. The doctor performing contract service is entitled to have parts of this contract that he cannot perform himself performed by another doctor as contract service by "referral" . If it is not possible for the doctor who has acted on referral to carry out consultant examination without consulting further doctor, the doctor who carries out the consultant examination can have individual services performed by another doctor as contract services.

13. If the doctor, who has acted on referral, treats an accident that only occurred during his treatment or only became known during his treatment, he also ticks the accident field.

2.2. Sample 30: Health examination report form

The following point has been added:

3. The documentation can optionally be provided with the same content in electronic form in the Documentation by the doctor.

2.3. Sample 40: Documentation form for early cancer detection examinations for men

The following sentence is added:

The documentation can optionally be included in the documentation in electronic form with the same content by the doctor.

2.4. Samples 71 and 71A are deleted.

2.5. The note "Samples 72 to 79 unoccupied " is changed to:

"Samples 71 to 79 unoccupied".

2.6. The note "Samples 82 to 98 unoccupied" is changed to:

" Samples 82 to 84 unoccupied ”.

2.7. The following text has been added to the explanations of the form:

Sample 85: Proof of entitlement to claim if the claim is suspended in accordance with Section 16 (3a) SGB V

Without explanation

Samples 86 to 98 unoccupied.

The table of contents changes accordingly.

3. This agreement comes into force on April 1, 2011.

Old forms from samples 63 and 80 must be used up.

National Association of Statutory Health Insurance Physicians, K. d. ö. R., Berlin

GKV-Spitzenverband, K. d. ö. R., Berlin

Berlin, March 14, 2011