CARONDELET HEALTH NETWORK A MEMBER OF ASCENSION HEALTH F AC S I M I L E T R AN S M I T T A L S H E E T
DATE: TO: ROBIN MARCELLO/ERIKA GONZALEZ/LISA
P R IO R A U T H O R IZ A T I O N :
The authorization team is available to assist with getting most
Would you like the authorization team to obtain prior Authorization?
CONFIDENTIALITY STATEMENT
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CARONDELET HEALTH NETWORK A MEMBER OF ASCENSION HEALTH The following paper work needed to complete your request:
All clinical history and progress notes
Physician NPI Valid contact number for patient and or demographic sheet
Copy of insurance card front and back (if applicable)
Order with Diagnosis (ICD 9) and Procedure (CPT). Please list codes if available. Please note:
If order is received at 2pm business day; process will not begin till next business day.
Please be aware that if you would like to assist with an authorization, the patient will be scheduled 5 days out to allow enough time for us to obtain the authorization.
In order to expedite all STAT cases, authorizations must be provided at time of scheduling. Due to urgent nature, we are unable to assist with authorizations for STAT cases.
All STAT’s must be called in to schedule.
We will contact patient if any of the information below is not filled out. DO NOT HAVE TO FILL OUT IF CONTACT INFORMATION OR DEMOGRAPHIC SHEET IS SENT! First Name: Middle Initial: Last name:
DOB: Contact number:
(if applicable) Patient Preference (day of the week, time of day and facility): (if applicable) If copies of report needs to be sent to additional physicians, please provide full name:
(IF ABLE & APPLICABLE) Information needed for specific types of exams:
CT
Any known Allergies to dyes? Yes No
Is patient 75 or older? Yes No If yes, we need current (within 90 days) creatinine levels.
If yes, if patient is taking metformin, glucophage, or glucovance- they must stop taking medications for 48 hours after the exam; We will need current (within 90 days) creatinine levels.
Any history of kidney disease or dialysis or CHF? Yes No
If yes, we need current (within 90 days) creatinine levels.
What was the first day of last menstrual period? ____________________________________________________________
MRI
Any metal in the body? Pacemaker Yes No Aneurysm clips yes No Cardiac valve replacements yes No Stimulators Yes No Other: ___________________________________________________________________
What was the first day of last menstrual period? ____________________________________________________________
Claustrophobic? Yes No if yes, will sedation be provided? Yes No Please note: sedation must be provided by physician.
Any history of kidney disease or dialysis or CHF? Yes No If history of kidney disease, we will need current (90 days) creatinine levels.Abdominal Ultrasound CARONDELET HEALTH NETWORK A MEMBER OF ASCENSION HEALTH
Is patient able to fast? Yes No if patient has any problems with fasting we will schedule the exam in the early morning.
Dexa
Any metal plates, rods, or pins in the lower back or hip area? Yes No If yes, explain:
Any previous exams, with contrast, within 7 days prior to appointments date? Yes No
(If able and applicable) Additional information needed for exams:
Patients Height and weight.________________________________________________________________
Any special needs (i.e. Wheelchair, crutches, canes, mentally handicapped, vision impaired, Needs interpreter, IV tubing, catheters?
If yes, explain: __________________________________________________________________
Please note: if patient requires lifting he or she will be scheduled at the hospital. _________________________________________________________________________________________
We do not schedule: List of facilities: SMIC 395 N. Silverbell Road, Suite 185 CIC GVIC RR CSJ Hospital CSM Hospital
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