What Medical Records Do I Need to Qualify for Medical Marijuana in Ohio?

In order to qualify for medical marijuana treatment in Ohio, you will need a copy of your medical records that documents that you are suffering from one of the 21 qualifying conditions. 

To better understand what type of records are sufficient and which are insufficient, we have created a guide that provides an overview for each condition. To learn more information about the type of medical records you will need for your appointment, please select the appropriate qualifying condition below.

General Considerations for Medical Records

Sufficient medical records
 

• Medical records fall under the rules of HIPAA 

• Medical records should not be emailed unless the system is encrypted 

• Proper legibility 

• Medical records must have proper attribution 

  • Name of patient with additional identifying features such as Date of Birth

  • Name of the doctor providing the service or commentary

  • Location of service

  • Date of Service

  • Relevant to Qualifying Condition (QC) 

In the State of Ohio, certification of a patient’s diagnosis can be made from medical records provided by an MD or DO who is licensed in the State of Ohio. This requirement is found in OAC Rule 4731-32-(B)(11) under the section of “Standard of Care.” 

 

Note: Workarounds may be possible when records are from out-of-state or when records are not from acceptable sources. 

Acceptable Sources of Medical Records

The following are sources and types of records that are acceptable.

PCP – Primary Care Physician 

o Must be a licensed Ohio physician (MD or DO) 
 

Specialist – Medical Specialist related to the Qualifying Condition 

o Must be a licensed Ohio physician (MD or DO) 
 

• Letter

o Must come from a physician (MD or DO) licensed in the state of Ohio 

o Must include description of QC o Should provide evidence of ongoing treatment supported by additional medical 

   records or narrative 
 

• Prescription 

o Generally unacceptable if only the diagnosis is written plus signature

o The script cannot request a medical marijuana card o Should provide evidence of ongoing treatment supported by additional medical records or narrative 
 

Progress Notes 

o Must show direct physician attribution (see PA and NP below)

o Must relate to qualifying condition

o Timeline should relate to nature of qualifying condition 
 

MyChart Face Sheet or Index 

o Unacceptable without physician attribution

o Must be supported by relevant offices notes or records 
 

Hospital Discharge Summary (HDS) 

o Must be relevant to QC

o Timeline should relate to nature of qualifying condition 
 

• Emergency Room (ER) Report 

o Must be relevant to QC

o Timeline should relate to nature of qualifying condition 
 

• Laboratory report 

o Must be relevant to QC o Supplemental to Progress Note from PCP or Specialist
o May occasionally stand-alone (HIV, Hepatitis C) 
 

• Pathology Report 

o Must be relevant to QC o Supplemental to Progress Note from PCP or Specialist
o May occasionally stand-alone (cancer, Crohn’s disease, CUC) 

• X-ray Report 

o Must be relevant to QC o Supplemental to Progress Note from PCP or Specialist 

• Operative Report 

o Must be relevant to QC o Supplemental to Progress Note from PCP or Specialist o May occasionally stand-alone depending on narrative in report 

• Endoscopy Report 

o Must be relevant to QC o Supplemental to Progress Note from PCP or Specialist o May occasionally stand-alone depending on narrative in report 
 

• Optometrist 

o Related to diagnosis of glaucoma o Attribution to ophthalmologist 
 

• Confirmation of disability 

o From a government agency or insurance company supported by relevant medical 

records

Unacceptable Sources of Medical Records

The following are sources and types of records that are unacceptable and cannot be used for review during your evaluation.

• PA/NP – Physician Assistant or Nurse Practitioner 

o Unless record has direct attribution to a physician (MD or DO) 
 

Chiropractor 

o Usually for a diagnosis of chronic pain, less commonly for spinal cord injury or disease o Excluded by OAC 4731-32-(B)(11) 
 

Psychologist 

o Usually for diagnosis of PTSD o Excluded by OAC 4731-32-(B)(11) 
 

• Podiatrist 

o Usually for diagnosis of chronic foot pain or plantar fasciitis 

o Excluded by OAC 4731-32-(B)(11) 
 

• Non-Ohio Physician 

o Excluded by OAC 4731-32-(B)(11) o Records must go through Ohio physician showing evidence of ongoing treatment in collaboration or locally 

Other Considerations When Gathering Medical Records

Age of Records: The OAC rules in 4731-32 make no mention about the age of medical records used to confirm a diagnosis. However, the rule specifically states that the confirming physician must be satisfied with the quality of the records (Key: Documentation supported the decision to recommend) 
 

Telemedicine: The OAC rules for Standard of Care in 48731-32 specify that the evaluation of a patient requesting a MM recommendation must be bonafide and in-person. However, telemedicine records are not excluded as long as they again are satisfactory in quality. 

Out-of-State Records: Out of state records are problematic. The OAC rule specifically states that the QC diagnosis must come from an Ohio-based MD or DO. In some cases, records for a clearly defined qualifying condition must be filtered through the patient’s in-state PCP or Specialist. Records from an out-of-state psychologist indicating a diagnosis of PTSD are unacceptable. 

Acceptable Medical Records for Each Qualifying Condition
To provide an even better understanding of what medical records are sufficient in order to qualify for medical marijuana, you will find an overview of each qualifying condition the types of documents that are acceptable to bring to your appointment.

 

Amyotrophic Lateral Sclerosis (ALS) 

ALS, or amyotrophic lateral sclerosis (also known as Lou Gerig’s Disease), is a progressive neurodegenerative disease that affects nerve cells in the brain and the spinal cord. 
 

• Treatment can help, but this condition can't be cured 

• Requires a medical (clinical) diagnosis 

• Lab tests or imaging always required to exclude other conditions 

• Chronic: can last for years or be lifelong and eventually terminal 

ALS is primarily diagnosed based on detailed history of the symptoms and signs observed by a physician during physical examination along with a series of tests to rule out other mimicking diseases. However, the presence of upper and lower motor neuron symptoms strongly suggests the presence of the disease. Tests that may be performed to exclude other diseases would include spinal tap, CT scan, MRI. 
 

Acceptable Records: 

• PCP 

• Neurologist 

• Hospice Physician possibly with supporting test results 

AIDS - acquired immune deficiency syndrome (Positive status for HIV) 

HIV is the virus that causes AIDS. AIDS stands for Acquired Immune Deficiency Syndrome. HIV and AIDS are not the same thing. And people with HIV do not always have AIDS. 

AIDS diagnosis requires:

(1) a confirmed, positive test for HIV ("HIV positive" test) and

(2) evidence of an AIDS-defining condition or severely depleted CD4 cells 

 

AIDS is an advanced stage of HIV infection and requires that the person have evidence of a damaged immune system. 

Acceptable Records 

• PCP 

• Infectious Disease Specialist 

• HIV/AIDS Clinic with physician attribution 

• Laboratory confirmation 

 

Alzheimer’s Disease 

Alzheimer's Disease is a type of dementia. No single test exists to determine if someone has dementia. The diagnosis of Alzheimer's Disease and other types of dementia is based on a careful medical history, a physical examination, laboratory tests, and the characteristic changes in thinking, day-to-day function and behavior associated with each type. AD can be definitively diagnosed only after death, by linking clinical measures with an examination of brain tissue in an autopsy. Occasionally, biomarkers—measures of what is happening inside the living body—are used to diagnose Alzheimer's. Other tests are performed to rule out other possible causes of impairment. 

Acceptable Records 

• PCP 

• Neurologist 

• Supplemental x-rays: CT or MRI of the brain 

 

Chronic Traumatic Encephalopathy (CTE) 

Chronic traumatic encephalopathy (CTE) is a neurodegenerative disease caused by repeated head injuries. Symptoms may include behavioral problems, mood problems, and problems with thinking. Symptoms typically do not begin until years after the injuries. CTE often gets worse over time and can result in dementia. 

CTE is a clinical diagnosis. There is currently no way to diagnose CTE by laboratory or x-ray. A definitive diagnosis requires evidence of degeneration of brain tissue and deposits of tau and other proteins in the brain that can be seen only upon inspection after death (autopsy). 

Acceptable Records 

• PCP 

• Neurologist 

• Supplemental x-rays: CT or MRI of the brain 

• Prior ER or HDS reports may supplement report from PCP or Neurologist 

 

Cancer

Cancer is the uncontrolled growth of abnormal cells in the body. Cancer develops when the body's normal control mechanism stops working. Old cells do not die and instead grow out of control, forming new, abnormal cells. These extra cells may form a mass of tissue, called a tumor. Some cancers, such as leukemia, do not form tumors. 

 

Cancer may occur anywhere in the body. Aside from skin cancer, breast cancer is the most common cancer in women. In men, it is prostate cancer. Lung cancer and colorectal cancer are the next most common cancers affecting both men and women. 

 

Aside from the direct effects of cancer on body tissues, both primarily and secondarily (metastases), treatment of cancer may result in temporary and life-long morbidities. 

Acceptable Records 

• PCP 

• Surgeon 

• Oncologist including radiation oncologist 

• Laboratory records 

• Radiology reports 

• Pathology reports 

• Operative and endoscopy reports 

• Hospice records with physician attribution 

 

Crohn’s Disease 

Crohn’s disease is a type of inflammatory bowel disease that can affect the entire gastrointestinal tract. 

The diagnosis of Crohn's disease is suspected in patients with fever, abdominal pain and tenderness, diarrhea with or without bleeding, and anal diseases, such as ulcers or fissures. ... Colonoscopy is more accurate than barium X-rays in detecting small ulcers or small areas of inflammation of the colon and terminal ileum. 

Crohn’s disease is treated by a variety of methods including non-steroidal anti-inflammatory medications, steroid, biologics and surgery. Crohn’s disease can be refractory to all of these and is generally considered incurable. 

Acceptable Records 

• PCP 

• Surgeon 

• Gastroenterologist 

• Laboratory records 

• Radiology reports 

• Pathology reports 

• Operative and endoscopy reports 

 

Epilepsy and other seizure disorders

Epilepsy is a central nervous system (neurological) disorder in which brain activity becomes abnormal, causing seizures or periods of unusual behavior, sensations, and sometimes loss of awareness. Essentials for diagnosis include a neurological exam, electroencephalogram (EEG), CT Scan or MRI. 

A select group of seizures in children is treated with high doses of CBD: EPIDIOLEX is indicated for the treatment of seizures associated with Lennox-Gastaut syndrome (LGS) or Dravet syndrome (DS) in patients 2 years of age and older. 

Acceptable Records 

• PCP 

• Neurologist including a pediatric neurologist 

• Supplemental x-rays: CT or MRI of the brain 

• Possibly Neurosurgeon 

 

Fibromyalgia

Fibromyalgia is a clinical diagnosis based on a symptom complex of pain with multiple supporting criteria: 
 

• Widespread pain lasting at least three months 

• Presence of other symptoms such as fatigue, waking up tired and trouble thinking 

• No other underlying condition that might be causing the symptoms 
 

Acceptable Records 

• PCP 

• Rheumatologist (preferred) 

• Neurologist (possibly) 

• Supplemental x-rays: CT scans or MRI of the brain 
 

Unacceptable Records 

• Chiropractic records without MD or DO attribution 

• Physical Therapy records 

 

Glaucoma

Glaucoma is associated with increased intra-ocular pressure. However, this finding is not the sole determinant of the diagnosis. 

Diagnostic studies include:
 

• Measurement of intra-ocular pressure 

• Inspection of the eye’s drainage angle 

• Examination of the optic nerve 

• Evaluation of peripheral vision 

• Measurement of corneal thickness 
 

Acceptable Records 

• PCP 

• Ophthalmologist (preferred) 

• Supplemental test results 

Records may come from an optometrist who can diagnosis and treat this condition. The OAC rule indicates that the diagnosis for confirmation must come from an Ohio-based MD or DO which can be problematic. A judgement for approval for recommendation must be made by the confirming physician with proper documentation. In some cases, the optometrist may be based in a clinic with ophthalmologists providing collaborative support. Likely, refractory glaucoma would be referred to an ophthalmologist for further treatment with MM being a later alternative. 

Hepatitis C 

Hepatitis C is one of several forms of a viral infection affecting the liver. The diagnosis is confirmed by laboratory analysis (and occasionally liver biopsy). Test results include: 

Non-reactive, or a negative, means that a person has never had hepatitis C. However, if a person has been recently exposed to the hepatitis C virus, he or she will need to be tested again. 

Reactive, or a positive, means that hepatitis C antibodies were found in the blood and a person has been infected with the hepatitis C virus at some point in time. A reactive antibody test does not necessarily mean a person has hepatitis C. Once someone has been infected, they will always have antibodies in their blood. This is true if even if they have cleared the hepatitis C virus.

 

Confirmation of diagnosis after a reactive antibody test requires an additional test, called a hepatitis C virus RNA test (or PCR), to confirm whether the virus is still present in the person’s bloodstream. 

Acceptable Records 

• PCP 

• Infectious disease specialist 

• Gastroenterologist (possibly) 

• Laboratory records 

• Pathology report (liver biopsy) 

Inflammatory Bowel Disease (IBD) 

Inflammatory bowel disease (IBD) is an umbrella term used to describe disorders that involve chronic inflammation of the digestive tract. Several causes exist for inflammation of the gut such as infection, toxin, autoimmune reaction, radiation and ischemia. When none of these causes are identified, a group of diseases with unknown etiology remains which are called chronic inflammatory bowel diseases (IBD). The most common chronic inflammatory bowel diseases include two distinct entities, ulcerative colitis (UC) and Crohn’s disease (CD). A subset of inflammatory bowel disease lacking specific diagnostic criteria is often called Indeterminate Colitis. 

Diagnosis and treatment of IBD follows the same pathways of Crohn’s Disease and Ulcerative Colitis. Care must be taken to avoid confusion with IBS (Irritable Bowel Syndrome) which is a functional disorder of the gastrointestinal tract. Signs and symptoms include cramping, abdominal pain, bloating, gas, and diarrhea or constipation, or both. 

Severe IBS could be a cause of chronic and severe abdominal pain. However, its symptoms would be considered under the category of Pain – Chronic/Severe/Intractable 

Acceptable Records 

• PCP 

• Surgeon 

• Gastroenterologist 

• Laboratory records 

• Radiology reports

 
 
 

Multiple Sclerosis (MS) 

Multiple sclerosis is primarily a clinical diagnosis. Multiple sclerosis (MS) is a potentially disabling disease of the brain and spinal cord (central nervous system). In MS, the immune system attacks the protective sheath (myelin) that covers nerve fibers and causes communication problems between your brain and the rest of your body. Eventually, the disease can cause permanent damage or deterioration of the nerves. 

Since no specific tests for MS exist, a diagnosis of multiple sclerosis relies on ruling out other conditions that might produce similar signs and symptoms. Tests utilized for this purpose may include: 

• Spinal tap (lumbar puncture 

• MRI 

• Evoked potential tests 

Pathologic finding of demyelination can be confirmed at autopsy securing a diagnosis. 

Acceptable Records 

• PCP 

• Neurologist 

• Supplemental x-rays: CT scans or MRI of the brain 

 

Pain - pain that is either chronic, severe or intractable 

Chronic pain is defined as pain that persists past normal healing time and hence lacks the acute warning function of physiological nociception. Usually, pain is regarded as chronic when it lasts or recurs for more than 3 to 6 months. The list of causes of chronic pain is extensive. For example, but not complete: 

  • Abdominal adhesions

  • Ankylosing spondylitis

  • Arthritis, osteo

  • Back pain, chronic

  • Bladder spasms

  • Blepharospasm (spasms of the eyelids)

  • Cyclical vomiting syndrome

  • Degenerative disk disease

  • Ehlers-Danlos Syndrome

  • Endometriosis

  • Failed back surgery

  • Gastroparesis

  • Gout or Pseudogout

  • Headache, recurrent (i.e. migraine)

  • Herniated disk(s) of the spine

  • Interstitial cystitis

  • Irritable Bowel Syndrome (IBS)

  • Joint pain, chronic

  • Lupus

  • Lyme Disease

  • Muscle spasms, chronic

  • Neck pain, chronic 

  • Neurogenic bladder

  • Pancreatitis, chronic

  • Peripheral arterial disease

  • Peripheral neuropathy

  • Polymyalgia rheumatica

  • Polymyositis

  • Premenstrual syndrome, severe

  • Psoriatic arthritis

  • Reactive arthritis

  • Reflex Sympathetic Dystrophy (RSD)

  • Rheumatoid Arthritis (RA)

  • Scleroderma

  • Spinal stenosis

  • Spondylitis

  • Spondylolisthesis

  • Tendinitis & Bursitis

  • Torticollis

  • Traumatic fracture

  • Trigeminal neuralgia

  • Uterine fibroids

  • Vasculitis

  • Vertebral compression fracture(s) 

When possible, the underlying cause of chronic pain should be attributed to a primary condition. 

The WHO in their upcoming issue of ICD-11 has created a logical method of defining chronic pain which may assist in the thought process of confirming this diagnosis. Chronic pain is defined over six categories: 
 

  1. Chronic primary pain 

  2. Chronic postsurgical or post-traumatic pain 

  3. Chronic secondary musculoskeletal pain 

  4. Chronic secondary visceral pain 

  5. Chronic neuropathic pain 

  6. Chronic secondary headache or orofacial pain 

 

Acceptable Records 

• PCP 

• Records from any physician (Ohio-based MD or DO) treating a condition causing chronic pain 

• Records must support the underlying condition causing the complaint of chronic pain. The record must also confirm chronicity. 

o Operative records o Hospital discharge summaries
o Radiological studies
o Select emergency room records 

• Additional attributes in the medical record: 

o Date of onset of pain (cause, accident, situation)
o Therapies attempted (successful and unsuccessful)
o Evidence of ongoing symptoms (dependent on age of medical record) 
 

Unacceptable Records 

• Chiropractic 

• Podiatry 

• Physical Therapy 

• Holistic centers 

• Personal trainers, Gyms, spas 

• Out-of-state records without proper in-state physician attribution 

 
 

Parkinson’s Disease

Parkinson’s Disease is a neurological disorder that generally has four cardinal symptoms: bradykinesia, tremor, rigidity, and postural instability also referred to as “parkinsonism.” Tremor is the most apparent and well-known symptom. 

 

No specific test exists to diagnose Parkinson's disease. Most often a neurologist will diagnose Parkinson's disease based on medical history, a review of signs and symptoms, and a neurological and physical examination. Supplemental testing may be used to differentiate from other neurological conditions with similar symptoms. 

Acceptable Records 

• PCP 

• Neurologist 

• Supplemental x-rays: CT scans or MRI of the brain 

Positive Status for HIV (Human Immunodeficiency Virus) 

HIV is the virus that causes AIDS. Being infected with the virus does not necessarily mean that the patient will progress to AIDS. 

 

There are three main types of HIV tests: antibody tests, RNA (viral load) tests, and a combination test that detects both antibodies and viral protein called p24 (antibody- antigen test, or HIV Ab-Ag test). All tests are designed to detect HIV-1, which is the type of HIV in the United States. 

Acceptable Records 

• PCP 

• Infectious Disease Specialist 

• HIV/AIDS Clinic with physician attribution 

• Laboratory confirmation 

 

Post-Traumatic Stress Disorder (PTSD) 

Posttraumatic stress disorder (PTSD) is a psychiatric disorder that can occur in people who have experienced or witnessed a traumatic event such as a natural disaster, a serious accident, a terrorist act, war/combat, rape or other violent personal assault. 

 

A doctor who has experience helping people with mental illnesses, such as a psychiatrist or psychologist, can diagnose PTSD. 

To be diagnosed with PTSD, an adult must have all the following for at least 1 month: 

• At least one re-experiencing symptom 

• At least one avoidance symptom 

• At least two arousal and reactivity symptoms 

• At least two cognition and mood symptoms 
 

Re-experiencing symptoms include: 

• Flashbacks—reliving the trauma over and over, including physical symptoms like a racing heart or sweating 

• Bad dreams 

• Frightening thoughts 

Re-experiencing symptoms may cause problems in a person’s everyday routine. The symptoms can start from the person’s own thoughts and feelings. Words, objects, or situations that are reminders of the event can also trigger re-experiencing symptoms. Avoidance symptoms include: 
 

• Staying away from places, events, or objects that are reminders of the traumatic experience 

• Avoiding thoughts or feelings related to the traumatic event 
 

Things that remind a person of the traumatic event can trigger avoidance symptoms. These symptoms may cause a person to change his or her personal routine. For example, after a bad car accident, a person who usually drives may avoid driving or riding in a car. Arousal and reactivity symptoms include: 
 

• Being easily startled 

• Feeling tense or “on edge” 

• Having difficulty sleeping 

• Having angry outbursts 
 

Arousal symptoms are usually constant, instead of being triggered by things that remind one of the traumatic events. These symptoms can make the person feel stressed and angry. They may make it hard to do daily tasks, such as sleeping, eating, or concentrating. 

Cognition and mood symptoms include: 
 

• Trouble remembering key features of the traumatic event 

• Negative thoughts about oneself or the world 

• Distorted feelings like guilt or blame 

• Loss of interest in enjoyable activities 
 

Cognition and mood symptoms can begin or worsen after the traumatic event but are not due to injury or substance use. These symptoms can make the person feel alienated or detached from friends or family members. 
 

Acceptable Records 

• PCP 

• Psychiatrist 

• Records from a government agency (VA) with physician attribution 

Unacceptable Records 

• Reports from 

o Psychologist o Social Worker 

o Mental health counsellor 

• Out-of-state assessment regardless of attribution 

 

Sickle Cell Disease 

Sickle cell disease is an abnormality of the hemoglobin in the red blood cell. Under certain circumstances a sickle cell crisis can occurs resulting in acute symptoms followed by chronic problems: 
 

• Fatigue and anemia. 

• Pain crises. 

• Dactylitis (swelling and inflammation of the hands and/or feet) and arthritis. 

• Bacterial infections. 

• Sudden pooling of blood in the spleen and liver congestion. 

• Lung and heart injury. 

• Leg ulcers. 

• Aseptic necrosis and bone infarcts 

• Eye damage 
 

Sickle cell disease is diagnosed by examining a sample of blood. The test used is hemoglobin electrophoresis, which determines the type of hemoglobin one has, and if he or she is a carrier or has the disease. When the abnormal sickle-shaped cells in the blood are identified, a diagnosis is made. 
 

Smoking and vaping should be discouraged in individuals with sickle cell trait and disease.
 

Acceptable Records 

• PCP 

• Hematologist 

• Laboratory report (hemoglobin electrophoresis)

 

Spinal Cord Disease or Injury

A traumatic spinal cord injury may happen because of a sudden blow or cut to the spine resulting in damage to the spinal cord, the major column of nerve tissue that is connected to the brain and lies within the vertebral canal and from which the spinal nerves emerge. A spinal cord injury often causes permanent loss of strength, sensation, and function below the site of the injury. Rehabilitation and assistive devices allow many people with spinal cord injuries to lead productive, independent lives. Treatments include drugs to reduce symptoms and surgery to stabilize the spine. 

 

Spinal cord diseases or disorders are those conditions of congenital or disease onset causing symptoms, treatments and prognosis's affecting mobility or sensation. These conditions include: 

• Arachnoiditis 

o Arachnoiditis information sheets and on-line support 

• Arterial-venous Malformation 

o Arteriovenous Malformation information sheet 

• Brown-Sequard Syndrome 

o Brown-Sequard information

o Brown-Sequard articles 

• Cauda Equina Syndrome 

o Cauda Equina Syndrome Fact Sheet 

• Central Cord Syndrome 

o Central Cord Syndrome information

o Info from AANS 

• Guillain-Barré Syndrome 

o Guillain-Barré Syndrome 

• Back and spine conditions/disorders 

• Multiple sclerosis 

o Multiple Sclerosis Coalition

o MS Survey-Mental Health Assistance

o Economics of Living with Multiple Sclerosis

o Alternative Medicine and MS

o Multiple sclerosis information sheets and organizations

o MS and spasticity

o MS and Vitamin D

o MS Coalition-Disease Modifying Therapy 

• Polio/post-Polio 

o Polio/Post-Polio resources 

• Spinal Cord Tumor 

o Spinal Cord Tumor-General Information & Support 

• Spina Bifida 

o Intro to Spina Bifida

o Spina Bifida resources

o Spina Bifida-A Personal Perspective 

• Spinal Muscular Atrophy 

o Muscular Dystrophy Association-SMA

o Spinal Muscular Atrophy Description-NIH 

• Spinal Stenosis 

o Spinal Stenosis causes, diagnosis, and treatment 

• Stroke/spinal 

o Spinal stroke 

• Syringomyelia 

o Syringomyelia information page and on-line support

o Chiari Malformation-basic information from NINDS 

• Tarlov Cysts 

o Tarlov Cyst Information 

• Transverse Myelitis 

o Transverse Myelitis resources 

Acceptable Records 

• PCP 

• Neurosurgeon 

• Neurologist 

• Supplemental x-rays: CT scans or MRI of the brain 

• Spine center with physician attribution (Ohio-based) 
 

Unacceptable Records 

• Chiropractic records without MD or DO attribution 

• Physical Therapy records 

 

Traumatic Brain Injury (TBI) 

TBI is a clinical diagnosis; no single test can definitively confirm the diagnosis of TBI. Criteria include a history of an injury affecting the brain, the patient's symptoms, the physical examination and additional tests, including neuroradiology, to confirm a diagnosis.

 

Acceptable Records 

• PCP 

• Neurologist 

• Supplemental x-rays: CT or MRI of the brain 

• Prior ER or HDS reports may supplement report from PCP or Neurologist 

 

Tourette’s Syndrome 

Tourette’s Syndrome is a neurologic disorder characterized by involuntary tics. There's no specific test that can diagnose Tourette syndrome. The diagnosis is based signs and symptoms. The criteria used to diagnose Tourette syndrome include: 
 

• Both motor tics and vocal tics are present, although not necessarily at the same time 

• Tics occur several times a day, nearly every day or intermittently, for more than a year 

• Tics begin before age 18 

• Tics aren't caused by medications, other substances or another medical condition 

• Tics must change over time in location, frequency, type, complexity or severity 
 

Acceptable Records 

• PCP 

• Neurologist 

• Psychiatrist 

• Supplemental x-rays: CT scans or MRI of the brain 

 

Ulcerative Colitis

Ulcerative colitis is a type of inflammatory bowel disease manifesting most often with bloody diarrhea and other extra-intestinal symptoms (anemia, fatigue, skin changes, arthritis and liver abnormalities). 

 

Ulcerative colitis is diagnosed after ruling out other possible causes. A diagnosis of ulcerative colitis may be confirmed one or more of the following tests and procedures: 

• Blood tests 

• Stool sample 

• Colonoscopy with biopsy 

• Flexible sigmoidoscopy 

• X-rays including CT scan Computerized tomography (CT) enterography and magnetic resonance (MR) enterography 

• Surgery 
 

Acceptable Records 

• PCP 

• Surgeon 

• Gastroenterologist 

• Laboratory records 

• Radiology reports 

• Pathology reports 

• Operative and endoscopy reports