Client Data

Please select the reporting period

Beginning – 12/31/2013
1/1/2014 – 3/31/2014
4/1/2014-6/30/2014
7/1/2014-8/31/2014

Table 1: Chronic condition(s)

		Qualifying Chronic Condition (s)
Location	Client No.	(DM) Diabetes Mellitus Type II	Cardiovascular Disease (CVD) including hypertension	Congestive Heart Failure (CHF)	Coronary Artery Disease (CAD)	Chronic Obstructive Pulmonary Disease (COPD)	Other Influential Condition(s)

Please select the reporting period

Beginning – 12/31/2013
1/1/2014 – 3/31/2014
4/1/2014-6/30/2014
7/1/2014-8/31/2014

Table 2: Payer information

		Payer
Location	Client No.	Medicare	Medicaid	Private/ Commercial Insurer	Other (free text)	None

Please select the reporting period

Beginning – 12/31/2013
1/1/2014 – 3/31/2014
4/1/2014-6/30/2014
7/1/2014-8/31/2014

Table 3: Intervention Characteristics

Intervention Characteristics
Location	Client No.	Intervention Start Date	Intervention Goal	Intervention Activities/Design	Update on achievement of goals	Partners involved in intervention

Please select the reporting period

Beginning – 12/31/2013
1/1/2014 – 3/31/2014
4/1/2014-6/30/2014
7/1/2014-8/31/2014

Table 4: Additional Resources Required

Additional Resources Required
Location	Client No.	Were any additional resources used?	Financial (free text)	Equipment (free text)	Volunteer work (free text)	Other (explain)

Please select the reporting period

Beginning – 12/31/2013
1/1/2014 – 3/31/2014
4/1/2014-6/30/2014
7/1/2014-8/31/2014

Table 5: Intervention Completion Information

Intervention Completion Information
Location	Client No.	Intervention Completion Date	Reason for Completion: Achieved intervention goal	Reason for Completion: Loss of interest by client	Reason for Completion: Moved	Reason for Completion: Death	Reason for Completion: Other (explain)