Surgery Scheduling Plan

Surgeon:

CSN:

Date of Surgery:

Time of Surgery:

Patient Name (Last, First, MI):

DOB:

BASE INFORMATION (Add Comments as necessary)

Pre-Op Visit Date:

Complete Order for Surgery

Admission Type

Date / Time

Physician Signature

Breast Form (if applicable)

30 Day Advance Sterilization Consent Form (OHP only)

H & P

Consent

Date / Time

Signed by Witness

Patient Signature

OTHER INFORMATION

Labs

EPIC

Elsewhere

Where:

Date Expected:

EKG

EPIC

Elsewhere

Where:

Date Expected:

Surgical Clearance if Needed

Pulminary

Medical

Cardiac

Other Special needs or pertinent patient information:

Pacer (include copy of pacer card)

ICD

Other (Explain):

Insurance Payor(s):

Expiration Date:

Pre-Auth Required? (Include copy of Insurance Card)

Primary

Yes

Secondary

No

Insurance Authorization Complete

Authorization #:

Care Management Referral Needed

Post-Op follow-Up Office Visit

Date / Time: TBD

CONTACT INFORMATION

Sent By:

Please fax packet to 503-814-2038

Please fill out the form completely. Any scheduling request with incomplete or missing required information, or any request that contains incomplete information, may result in a delay on your request.

For questions, please contact surgery scheduling intake at 503-561-5669.