{"aaData": [["<a href=\"../../vivian-data/123_5/123.5-1.html\">ALL SERVICES</a>", "", "", "", "", "", "", "", "", "", "", "", "<dl>\n<dd>\n<ul>\n<li>\n</li>\n<li>\n</li>\n<li>\n</li>\n<li>\n</li>\n<li>\n</li>\n<li>\n</li>\n</ul>\n</dd></dl>\n", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "<dt>GROUPER ONLY</dt>\n", "", "", "", "", ""], ["<a href=\"../../vivian-data/123_5/123.5-2.html\">MEDICINE</a>", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "<dt><a href=\"../../vivian-data/100_98/100.98-11.html\">CONSULTS</a></dt>\n", "", "<dt><a href=\"../../vivian-data/101/101-533.html\">GMRCRM MEDICINE REQUEST TYPES</a></dt>\n", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", ""], ["<a href=\"../../vivian-data/123_5/123.5-3.html\">PHARMACY SERVICE</a>", "", "", "", "", "", "", "", "", "", "<dl>\n<dd>\n<ul>\n<li>\n<dt>RX</dt>\n</li>\n</ul>\n</dd></dl>\n", "", "", "", "", "<dt><a href=\"../../vivian-data/100_98/100.98-11.html\">CONSULTS</a></dt>\n", "<dt><a href=\"../../vivian-data/19/19-1882.html\">GMRC PHARMACY TPN CONSULTS</a></dt>\n", "", "", "<dt><a href=\"../../vivian-data/101/101-541.html\">GMRCACTM PHARMACY PKG MENU</a></dt>\n", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", ""], ["<a href=\"../../vivian-data/123_5/123.5-4.html\">CARDIOLOGY</a>", "", "", "", "", "", "", "", "", "", "", "", "", "<dl>\n<dd>\n<ul>\n<li>\n</li>\n<li>\n</li>\n<li>\n</li>\n<li>\n</li>\n<li>\n</li>\n<li>\n</li>\n<li>\n</li>\n<li>\n</li>\n<li>\n</li>\n<li>\n</li>\n</ul>\n</dd></dl>\n", "", "<dt><a href=\"../../vivian-data/100_98/100.98-11.html\">CONSULTS</a></dt>\n", "<dt>File: 19, IEN: 1885</dt>\n", "", "", "<dt><a href=\"../../vivian-data/101/101-534.html\">GMRCACTM MEDICINE PKG MENU</a></dt>\n", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "<dt>D EN^<a href=\"../../dox/Routine_GMRCMER.html\">GMRCMER</a></dt>\n", "", "", "", ""], ["<a href=\"../../vivian-data/123_5/123.5-40.html\">EYEGLASS REQUEST</a>", "", "", "", "<dt>REQUIRE</dt>\n", "<dt>LEXICON</dt>\n", "", "", "", "", "", "", "", "", "", "<dt><a href=\"../../vivian-data/100_98/100.98-11.html\">CONSULTS</a></dt>\n", "", "", "<dt><a href=\"../../vivian-data/101/101-542.html\">GMRCACTM SERVICE ACTION MENU</a></dt>\n", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "<dt><pre>\nEYEGLASS RX:\n [NEAR]                  Right           Left\n \n Sphere  Cylinder:\n             Axis:\n            Prism:\n             Base:\n               BC:\n              MRP:\n -------------------------------------------------------------------------\n [NEAR]                  Right           Left\n [DISTANCE]              Right           Left\n               BC:\n              MRP:\n -------------------------------------------------------------------------\n [NEAR]                  Right           Left\n  Addition Height:\n             Type:\n            Width:\n          PD  Far:\n         PD  Near:\n   PD  Near Inset:\n Sphere  Cylinder:\n      Total Inset:\n -------------------------------------------------------------------------\n [FRAME SELECTION]\n     Frame Name:\n          Color:\n        Eyesize:\n    Bridge Size:\n  Temple Length:\n -------------------------------------------------------------------------\n [EYEWEAR OPTIONS]\n             Axis:\n Lens Material: [] Plastic      [] Glass        [] Polycarb\n \n    Lens Style: [] Single Vision\n                [] Bifocal\n                [] Trifocal\n                [] Lenses Only\n                [] Safety\n                [] Tint*\n                [] Progressive*\n                [] Other (Description):\n            Prism:\n *Medical Necessity (required) for Tint or Progressive:\n -------------------------------------------------------------------------\n SPECIAL INSTRUCTIONS FOR EYEWEAR FABRICATION:\n \n -------------------------------------------------------------------------\n DELIVERY INSTRUCTIONS: [] Veteran      [] VA Medical Center\n \n EYEGLASS REPLACEMENT:  [] Lost         [] Broken       [] Stolen\n -------------------------------------------------------------------------\n ####### (Information Below - to be completed by Prosthetics  #########\n             Base:\n \n ORDERING INFORMATION\n   Obligation #:\n     Total Cost:\n         VISA #:\n       EXP DATE:\n \n AUTHORIZATION SIGNATURE: ____________________________\n               BC:\n              MRP:\n -------------------------------------------------------------------------\n</pre>\n</dt>\n", "", "", "", "", "", "", "", "<dt>DISABLED</dt>\n", "", "", "", "", ""], ["<a href=\"../../vivian-data/123_5/123.5-41.html\">CONTACT LENS REQUEST</a>", "", "", "", "<dt>REQUIRE</dt>\n", "<dt>LEXICON</dt>\n", "", "", "", "", "", "", "", "", "", "<dt><a href=\"../../vivian-data/100_98/100.98-11.html\">CONSULTS</a></dt>\n", "", "", "<dt><a href=\"../../vivian-data/101/101-542.html\">GMRCACTM SERVICE ACTION MENU</a></dt>\n", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "<dt><pre>\nCONTACT LENS RX:\n   EDGE:\n -------------------------------------------------------------------------\n    MFG:            LENS TYPE:\n   TINT:            DOT:\n -------------------------------------------------------------------------\n        [] D.W. [] E.W. [] Mono\n -------------------------------------------------------------------------\n ISSUING INSTRUCTIONS:\n \n  [] See DR. for Dispensing\n                 Right           Left\n  [] Dispense Only\n  [] Replacement\n  [] Needs I&amp;R\n  [] Kit Training\n  [] Reinstruct\n  [] Other (Describe)\n -------------------------------------------------------------------------\n DELIVERY INSTRUCTIONS: [] Veteran      [] VA Medical Center\n \n EYEGLASS REPLACEMENT:  [] Lost         [] Broken       [] Stolen\n   Base:\n -------------------------------------------------------------------------\n ####### (Information Below - to be completed by Prosthetics  #########\n \n ORDERING INFORMATION\n   Obligation #:\n     Total Cost:\n         VISA #:\n       EXP DATE:\n \n AUTHORIZATION SIGNATURE: ____________________________\n  Power:\n    DIA:\n     OZ:\n  Thick:\n    SEC:\n    PER:\n</pre>\n</dt>\n", "", "", "", "", "", "", "", "<dt>DISABLED</dt>\n", "", "", "", "", ""], ["<a href=\"../../vivian-data/123_5/123.5-42.html\">HOME OXYGEN REQUEST</a>", "", "", "", "<dt>REQUIRE</dt>\n", "<dt>LEXICON</dt>\n", "", "", "", "", "", "", "", "", "", "<dt><a href=\"../../vivian-data/100_98/100.98-11.html\">CONSULTS</a></dt>\n", "", "", "<dt><a href=\"../../vivian-data/101/101-542.html\">GMRCACTM SERVICE ACTION MENU</a></dt>\n", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "<dt><pre>\n(HOME OXYGEN)\n               O2@ LPM with exercise of:\n \n 2.  PRESCRIPTION FOR HOME OXYGEN\n \n                             LPM @ Rest:\n                         LPM Continuous:\n                    LPM During Exercise:\n                      LPM Exercise Only:\n                            LPM @ Night:\n                         LPM Night Only:\n REASON FOR REQUEST (complaints and findings):\n                         LPM Night Only:\n \n 3.  PRIMARY DELIVERY SYSTEM\n \n        [] Compressed Gas       [] Concentrator         [] Liquid System\n \n 4.  ADDITIONAL ITEMS\n \n        [] (steel) Portable Cylinders   [] (Aluminum) Portable Cylinders\n \n \n         Tank Size       Quantity per Month\n         -----           -----\n         -----           -----\n \n        [] Conserving Device (Type):\n \n        [] Nasal Cannula\n        [] Oxygen Mask\n        [] Trach Mask\n        [] Humidification\n \n        [] Other (e.g., cart, shoulder bag, etc.):\n \n DELIVERY LOCATION:\n \n 5.  LOGISTICS\n \n        [] Outpatient   [] Inpatient (Discharge Date):\n        [] Patient requires portable O2 for transport home\n        [] Patient requires recertification of prescription and follow-up\n           appointment: [] 6 months     [] 12 months\n 1.  RESULTS OF ARTERIAL BLOOD GASES OR PULSE OXIMETRY\n           Date of last visit:\n           Date of next visit:\n \n 6.  Does patient have advance directive on file?       [] Yes  [] No\n \n                       Room Air at Rest:\n                 Room Air with Exercise:\n                             O2@ LPM of:\n</pre>\n</dt>\n", "", "", "", "", "", "", "", "<dt>DISABLED</dt>\n", "", "", "", "", ""], ["<a href=\"../../vivian-data/123_5/123.5-43.html\">PROSTHETICS REQUEST</a>", "", "", "", "<dt>REQUIRE</dt>\n", "<dt>LEXICON</dt>\n", "", "", "", "", "", "", "", "", "", "<dt><a href=\"../../vivian-data/100_98/100.98-11.html\">CONSULTS</a></dt>\n", "", "", "<dt><a href=\"../../vivian-data/101/101-542.html\">GMRCACTM SERVICE ACTION MENU</a></dt>\n", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "<dt><pre>\n \n \n FOR (INPATIENT) - ESTIMATED DISCHARGE DATE:\n \n=======================================================================\n         (Describe PROSTHETIC APPLIANCE or REPAIR above LINE)\n \n ISSUING INSTRUCTIONS:\n        [] VETERAN WILL PICK UP\n        [] WARD/CLINIC PERSONNEL WILL PICKUP\n        [] DELIVERY LOCATION\n</pre>\n</dt>\n", "", "", "", "", "", "", "", "<dt>DISABLED</dt>\n", "", "", "", "", ""], ["<a href=\"../../vivian-data/123_5/123.5-44.html\">CARE COORDINATION HOME TELEHEALTH SCREENING</a>", "", "", "", "<dt>OPTIONAL</dt>\n", "<dt>LEXICON</dt>\n", "<dt>UNRESTRICTED</dt>\n", "", "", "", "<dl>\n<dd>\n<ul>\n<li>\n<dt>CCHT SCRN</dt>\n</li>\n</ul>\n</dd></dl>\n", "<dt>CCHT SC</dt>\n", "", "", "<dt>CCHT SCREENING</dt>\n", "<dt><a href=\"../../vivian-data/100_98/100.98-11.html\">CONSULTS</a></dt>\n", "", "", "<dt><a href=\"../../vivian-data/101/101-542.html\">GMRCACTM SERVICE ACTION MENU</a></dt>\n", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "<dt><pre>\nInitial Screening for Home Telehealth services.\n</pre>\n</dt>\n", "", "", "", "", "", "", "", "<dt>DISABLED</dt>\n", "", "", "", "", ""], ["<a href=\"../../vivian-data/123_5/123.5-45.html\">SUICIDE HOTLINE</a>", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "<dl>\n<dd>\n<ul>\n<li>\n</li>\n</ul>\n</dd></dl>\n", "", "", "<dt>TRACKING ONLY</dt>\n", "", "", "", "", ""], ["<a href=\"../../vivian-data/123_5/123.5-5.html\">GASTROENTEROLOGY</a>", "", "", "", "", "", "", "", "", "", "<dl>\n<dd>\n<ul>\n<li>\n<dt>GI</dt>\n</li>\n</ul>\n</dd></dl>\n", "<dt>GI</dt>\n", "", "<dl>\n<dd>\n<ul>\n<li>\n</li>\n<li>\n</li>\n<li>\n</li>\n<li>\n</li>\n<li>\n</li>\n<li>\n</li>\n</ul>\n</dd></dl>\n", "", "<dt><a href=\"../../vivian-data/100_98/100.98-11.html\">CONSULTS</a></dt>\n", "<dt>File: 19, IEN: 1885</dt>\n", "", "", "<dt><a href=\"../../vivian-data/101/101-534.html\">GMRCACTM MEDICINE PKG MENU</a></dt>\n", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "<dt>D EN^<a href=\"../../dox/Routine_GMRCMER.html\">GMRCMER</a></dt>\n", "", "", "", ""], ["<a href=\"../../vivian-data/123_5/123.5-6.html\">HEMATOLOGY</a>", "", "", "", "", "", "", "", "", "", "", "", "", "<dl>\n<dd>\n<ul>\n<li>\n</li>\n<li>\n</li>\n</ul>\n</dd></dl>\n", "", "<dt><a href=\"../../vivian-data/100_98/100.98-11.html\">CONSULTS</a></dt>\n", "<dt>File: 19, IEN: 1885</dt>\n", "", "", "<dt><a href=\"../../vivian-data/101/101-534.html\">GMRCACTM MEDICINE PKG MENU</a></dt>\n", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "<dt>D EN^<a href=\"../../dox/Routine_GMRCMER.html\">GMRCMER</a></dt>\n", "", "", "", ""], ["<a href=\"../../vivian-data/123_5/123.5-7.html\">PULMONARY</a>", "", "", "", "", "", "", "", "", "", "", "", "", "<dl>\n<dd>\n<ul>\n<li>\n</li>\n<li>\n</li>\n<li>\n</li>\n<li>\n</li>\n</ul>\n</dd></dl>\n", "", "<dt><a href=\"../../vivian-data/100_98/100.98-11.html\">CONSULTS</a></dt>\n", "<dt>File: 19, IEN: 1885</dt>\n", "", "", "<dt><a href=\"../../vivian-data/101/101-534.html\">GMRCACTM MEDICINE PKG MENU</a></dt>\n", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "<dt>D EN^<a href=\"../../dox/Routine_GMRCMER.html\">GMRCMER</a></dt>\n", "", "", "", ""], ["<a href=\"../../vivian-data/123_5/123.5-8.html\">RHEUMATOLOGY</a>", "", "", "", "", "", "", "", "", "", "", "", "", "<dl>\n<dd>\n<ul>\n<li>\n</li>\n</ul>\n</dd></dl>\n", "", "<dt><a href=\"../../vivian-data/100_98/100.98-11.html\">CONSULTS</a></dt>\n", "<dt>File: 19, IEN: 1885</dt>\n", "", "", "<dt><a href=\"../../vivian-data/101/101-534.html\">GMRCACTM MEDICINE PKG MENU</a></dt>\n", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "", "<dt>D EN^<a href=\"../../dox/Routine_GMRCMER.html\">GMRCMER</a></dt>\n", "", "", "", ""]]}