Attending(Surgeon) Name: Hospital’s Last, First, Middle Name: Initial Physician’s _____________________________________________________ Medicaid 12-digit Provider ID #: Street Address:_______________________________________ Hospital Requestor Name: City: _______________________________________________ _____________________________________________________ State: ______________________________________________ () - - Phone #: Zip Code: Ext. () - Phone #: email: Medicaid ID # ________________________________________________ _____________________________ Participant Medicaid ID Number: Elective Back Surgery // Participant Last/First/Middle Name: Date of Birth: _____________________________________ // (Proposed) Admission date: ICD-9-CM DIAGNOSIS NARRATIVE DESCRIPTION(S) CODE(S) 1. Scheduled Date ICD-9-CM Procedure Code(s) Procedure Description(s) // // // // //
Hospital’s Name: _____________________________________________________ Medicaid 12-digit Provider ID #: Hospital Requestor Name: _____________________________________________________ Phone #: () - Ext. email: ________________________________________________ Attending(Surgeon) Physician’s Name: Last, First, Middle Initial Street Address:_______________________________________ City: _______________________________________________ State: ______________________________________________ Zip Code: - Phone #: () - Medicaid ID # _____________________________ Participant Medicaid ID Number: Elective Back Surgery Participant Last/First/Middle Name: _____________________________________ Date of Birth: // (Proposed) Admission date: // ICD-9-CM DIAGNOSIS CODE(S) NARRATIVE DESCRIPTION(S) 1. Scheduled Date ICD-9-CM Procedure Code(s) Procedure Description(s) // // // // //