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Check either # 1, #2 or
# 3 and follow the instructions.
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1.
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Create Claim in both ECMS(B)
and ECMS(E). Check either (a) or
(b) below:
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(a)
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Enter ALL medical conditions claimed on the form
(EE-1 or 2) in both ECMS (B) and (E)
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(b)
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Enter medical conditions
in ECMS (B) and (E) as specified below:
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Enter these conditions in ECMS - B
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Enter these conditions in ECMS- E
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2.
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Create Claim in ECMS(B)
only – Enter all claimed medical conditions only in ECMS(B)
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3.
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Create Claim in ECMS(E)
only – Enter all claimed medical conditions only in ECMS(E)
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Reviewer:
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Printed Name
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Signature
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Date
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Case Creator:
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Printed Name
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Signature
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Date
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