Surgery Scheduling Request Form - Anaheim, CA Regional ...

Surgery Scheduling Request Form FAX to Surgery Scheduling 714-999-6102

Scheduling Request Form Completed by: _______________________________________ Office Number (Direct Line):____________________________

Date Completed:______________________________________ Patient's SSN#:_______________________________________

Patient's Legal Name: (Last)____________________________ (First)___________________________________(MI) _______

Patient's Daytime Phone # _____________________________ Patient's Evening Phone #:______________________________

Patient's Allergies:____________________________________ Insurance:____________________________________________

* INSURANCE AUTHORIZATION #_FOR SURGERY______ _

______

Sex:

Age:

Date of Birth:

Surgeon: (Last Name)___________________________________ (First Name) __________________________________________

Assistant:_____________________________________________ Proctor (if applicable):___________________________________

Diagnosis (No CPT Codes):_____________________________________________________________________________________

___________________________________________________________________________________________________________

Procedure/Surgery:___________________________________________________________________________________________

___________________________________________________________________________________________________________

Patient Status: Out-Patient , AM Admit , In-Patient

Anesthesia: General , MAC , Other _________________

Date of Surgery: ____________ Time : _____________ Amount of time requested for surgery:_____________________________

Pre - Admissions Screening Appointment :

Primary Care Physician:_________________________________ Medical Group:________________________________________ Medical/Cardiac Clearance from:________________________________________________________________________________ Labs to be done at:______________________________________ H&P to be completed by:_________________________________ Abnormal Labs notified:_________________________________ at:_________________________ initials:____________________ Special Requests:____________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

Notes/Special Needs: (EXAMPLES: Patient deaf/mute, mental/developmental delayed, Skilled nursing facility, etc.)

____________________________________________________________________________________________________________

Surgery Scheduled by:

Date Scheduled:

UPDATED: 01/04/2010 *Cases without an insurance authorization number will not be scheduled

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