PSH Scheduling Fax Form

TO: FAX: PHONE: PAGES:

Scheduling Request

Panhandle Surgical Hospital Fax: (806) 212-0294 Quail Creek Surgical Hospital Fax: (806) 354-6162

DATE: FROM: OFFICE: PHONE:

Patient Name:

Date of Birth:

Social Security #:

Sex: Male Female

Surgeon:

Type of Anes:

Procedure:

Diagnosis: Requested* Date:

Time:

Estimated Duration:

Length of Stay:

* The requested Date and Time of the procedure is tentative until confirmed by Physicians Surgical Hospital's Scheduling Department.

PLEASE ATTACH A COPY (FRONT & BACK) OF THE PATIENT'S INSURANCE CARD

Please Complete the Following

Patient Address:

City:

State:

Employer:

Guarantor Name (If Minor):

OR Attach Demographic Information

Zip:

Home Phone:

Work Phone:

Phone:

Is this a Work Related Injury? If yes, Date of Injury:

Is this a Motor Vehicle Accident? If yes, Date of Injury:

Yes

No

Is Employer a TWCC Subscriber?

Yes

No

Yes

No

Driver at Fault:

Insurance Carrier: Insured Name: Effective Date: Network:

Benefit Phone: Policy #: Group #: Adjuster/Case Mgr:

The documents in this facsimile transmission may contain confidential health information that is privileged and legally protected from disclosure by federal law, the Health Insurance Portability and Accountability Act (HIPAA). This information is intended only for the use of the individual or entity named above. If you are not the intended recipient, you are hereby notified that reading, disseminating, disclosing, distributing, copying, acting upon or otherwise using the information contained in this facsimile is strictly prohibited. If you have received this information in error, please notify the sender immediately and destroy this facsimile.

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