Scheduling Form / FAX to 503-371-2820
Scheduler:
Brandi
Terri
Someone Else
Surgeon:
Date & Time Scheduled:
SURGERY DATE:
TIME:
DURATION:
Procedure
Implants / Supplies needed:
CPT Code(s):
(REQUIRED)
ICD10 Diagnosis Code(s):
H26.491
H26.492
H25.11
H25.12
H25.811
H25.812
H40.51
H40.52
H40.1113
H40.1123
H40.1131
H40.1132
H11.821
H11.822
H02.831/H02.834
Fillable
(REQUIRED)
RNFA Requested:
Yes
/
No
Interpreter Required (Physician office or NBSC?):
Yes
/
No
Overnight (6 hours or more):
Yes
/
No
X-ray Tech Required
Yes
/
No
Anesthesia Type:
General
MAC
Conscious Sedation
Local
Patient Name:
Birthdate:
Sex:
M
/
F
Address:
City:
State:
Zip Code:
Home Phone #
Cell Phone #
Work Phone #
Facility Phone #
Home Phone #2
Alternate Phone #
Cell Phone #
Home Phone #
Work Phone #
Fax #
Facility Phone #
Home Phone #2
Cell Phone #2
Alternate Phone #
Alternate Phone #
Home Phone #2
Home Phone #
Cell Phone #2
Cell Phone #
Work Phone #2
Work Phone #
Fax #
Facility Phone #
Facility Phone #2
BMI:
(Required)
EMPLOYER:
SS#:
FOSTER CHILD:
Yes
/
No
CASEWORKER NAME:
Phone #
Cell Phone #
Work Phone #
Facility Phone #
Home Phone #2
Alternate Phone #
Fax #
Cell Phone #
Home Phone #
Work Phone #
Facility Phone #
Home Phone #2
Cell Phone #2
Alternate Phone #
Alternate Phone #
Home Phone #2
Home Phone #
Cell Phone #2
Cell Phone #
Work Phone #2
Work Phone #
Fax #
Facility Phone #
Facility Phone #2
IF PATIENT IS A MINOR LIST RESPONSIBLE
PARENT / GUARDIAN:
Parent Name:
Birthdate:
EMPLOYER:
PRIMARY INSURANCE:
Medicare
Atrio
BCBS
Regence
Providence
Health Net
Cigna
Pacific Source
Regence Med Advantage
Regence BCBS
AARP
WVCH
DMAP
Moda
Providence PEBB
Tricare
United Health Care
Not Listed
Self-Pay
ID #:
GROUP #:
AUTH #:
Not Required
DATES:
SECONDARY INSURANCE:
ID #:
GROUP #:
Notes
PRINT FORM
