// (Proposed) Admission date: ICD-9-CM DIAGNOSIS NARRATIVE DESCRIPTION(S) CODE(S) 1. Scheduled Date ICD-9-CM Procedure Code(s) Procedure Description(s) // // // // // // // PAST TREATMENTS
(Proposed) Admission date: // ICD-9-CM DIAGNOSIS CODE(S) NARRATIVE DESCRIPTION(S) 1. Scheduled Date ICD-9-CM Procedure Code(s) Procedure Description(s) // // // // // // // PAST TREATMENTS
Template%20Prior%20Auth%20for%20Elective-Back%20Surgery.docx