If not seekm ul1J2.rova/ c'.lS a Craniofacial Team. skip to Standard 2.

Craniofacial (surgery involving a transcranial procedure) Teams must meet Standards 1.1 through 1.3 related to Team Composition, as well as the following Standard.

To view examples of standard 1.4 documentation that Teams have submitted as evidence of compliance of the Standards for Cleft Palate and Craniofacial Teams, please visit: http://www,aopa-cpf,omlstagdards-examples

1.4 The Craniofacial Team must include a craniofacial surgeon who has specialized training and experience in surgical management of patients with syndromic and other craniofacial anomalies. Such training includes surgical procedures for syndromic patients involving the maxillofacial and craniofacial structures, and must include transcranial surgery. In addition, the Craniofacial Team must have access to a psychologist who does neurodevelopmental and cognitive assessment. The results of the neurodevelopmental and cognitive assessment must be part of the CFT team assessment record. The Team also must demonstrate access to refer to a neurosurgeon, ophthalmologist, radiologist, and geneticist. The participation of these individuals should be documented in each patient's team report.

8. List the name of the Team's lead member trained in transcranial craniofacial surgery.M.D., F.A.C.S., F.A.A.P.

Application for Approval of Teams Revised March 2017

Page 5

ACTION PLAN:

Name:.

Page 2 of 2

1. Please call to schedule a follow up appointment with Dr in April. 2. Follow up with Dr. as scheduled, May 9, 2016 at 1 :00 pm.3. Follow up with Dr. ugust 16, 2016 at 11 :00 am.4. Please call o schedule a follow up appointment with Dr.

Copy to: Dr.

If you have any questions about any of the recommendations, please call

------- . -- - - - -G dob:�

Referral Order ITo Provider

Phone: Phone: Fax: Fax:

Referral Order Information

I Diagnosis

I lnterfrontal craniofaciosynostosis

: ICD-9: 756.0: Anomalies of skull and face bones

Order Name Orders included: 1

lnterfronta

l craniofaciosynostosisICD-9: 756.0: Anomalies of skull and face bones • PEDIATRIC GENETICS REFERRAL

(1.4.11 )_ If applying as a CFT, provide an example or a patient that requires transcranial surgery thal documents a referral from the team to a specialist listed in 1.4.1 O.

Schedule Within: provider's discretion Note to Provider: Please call patient to schedule

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Patient Information

I Pa

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Name

ISex - DOB • Age

IAddress i I

Primary Insurance

Eligibility; Member 11 eligible. {Verified 08/13/2016) F==============�

I Secondarylns_urance ]I None recorded.

MD

MD02/24/2015 4:40pm

Humpty Dumpty Assessment: Humpty Dumpty Screen:Age:

Gender: Diagnosis:C ognitive Impairments:Environmental Factors:Medication Usage:Total:

Minimum Score 6 Maximum Score 19

<3yo(4)M or F < 3yo (3)Other (1)Forgets Limitations (2) None (1) Other med/None(1)12

At risk for Falls Yes (If Score 12 or greater) mom and dad aware of limitations, no arm bands available

Assessment/ Plan

1. I discussed our findings with Mr. and Mrs.� 2. I indicated that it is my impression that �ent findings compatible with the presence of an underlying genetic disorder3. It is important that we proceed with genetic testing to determine the cause of craniosynostosis and develop a proper plan of care,

treatment and � surveillance for

4. developmentalsurve1 lance is indicated and we would like to enroll .alllour program5. no changes in diet at this time 6. follow up in 6 months

1. Craniosynostosis syndrome

R •

756.0: Anomalies of skull and face bones

MD for Established Patient 15 atMD for Established Patient 15 at

MD, 06/07/2015.

n 06/09/2015 at 02:30 PMon 12/03/2015 at 10:30 AM