() - Ext. Phone #: email: Medicaid ID # ________________________________________________ Participant Medicaid ID Number: Elective CABG // ____________________________ Participant Last/First/Middle Name: Date of Birth: PREADMISSION INFORMATION // (Proposed) Admission date: ICD-9-CM DIAGNOSIS NARRATIVE DESCRIPTION(S) CODE(S) 1. Scheduled Date ICD-9-CM Procedure Code(s) Procedure Description(s) // // // //
Ext. email: ________________________________________________ Phone #: () - Medicaid ID # Participant Medicaid ID Number: Elective CABG Participant Last/First/Middle Name: ____________________________ Date of Birth: // PREADMISSION INFORMATION (Proposed) Admission date: // ICD-9-CM DIAGNOSIS CODE(S) NARRATIVE DESCRIPTION(S) 1. Scheduled Date ICD-9-CM Procedure Code(s) Procedure Description(s) // // // //