Patient Information Form (Surgery) - Dekalb Medical

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Patient Information (Required for Scheduling) **Please attach copy of Patient's driver license
Patient Name: _______________________________ DOB: ________________ Sex: ❑ M ❑ F SS#: ______ - _____ - ________
Last, First Name
Patient's Address: _________________________________ __________________________ ______________ _________________
Street
City
State
Zip Code
Home Phone#: _________________ Mobile Phone #: ___________________ Email Address: ___________________________
Primary Insurance: __________________________ Policy #: ______________ Group #: __________ Phone #: ______________
Plan & Product
If Commercial or Workers Comp, provide address: _________________________________________________________
Secondary Insurance: _______________________ Policy #: ______________ Group #: __________ Phone #: ______________
Plan & Product
If Commercial or Workers Comp, provide address: _________________________________________________________
Order Information - Surgery
Location: N. Decatur ______ Hillandale ______
SIS Confirmation #: ______________________
Date of Procedure: ____________________________________________
Nuclear Med prior to surgery/time: ____________
Time of Procedure: ____________________________________________
Needle Localization prior to sx/time: ___________
Length of Procedure: __________________________________________
Do you have other cases scheduled on this day?
YES
NO
❑
❑
If Yes, do you wish to change schedule order?
YES
NO
❑
❑
If Yes, please list patients by name in order: ______________________________________________________________________
Surgeon: _____________________________________________
Assist: _________________________________________________
Procedure: _____________________________________________________________________________________________________
CPT Codes: ____________________________________________________________________________________________________
Case Comments/Equipment: ____________________________________________________________________________________
Implants needed: ________________________________________________________________________________________________
Vendor Name: _________________________________________ Vendor contacted (D/T): _________________________________
Diagnosis: ______________________________________________________________________________________________________
ICD CM Codes: _________________________________________________________________________________________________
Anesthesia Type:
General
MAC
Local
Choice
❑
❑
❑
❑
Anesthesia Type for C-Sections:
Epidural
Spinal
❑
❑
Type of Admission:
Inpatient (Medicare IP only)
Inpatient (w/PreCert)
Inpatient/AM Admit
Outpatient
❑
❑
❑
❑
Person Requesting Scheduling: _______________________________________________ Date Faxed: _____________________
Confirmation Date: ____________________________ Pre-Screen Appointment: _________________________________
If Ophthalmology Patient:
Diabetic:
Yes
No
Natural Lens:
Yes
No
❑
❑
❑
❑
Referring Physician Information
Physician Name (first & last): ________________________________ NPI#: __________________ GA License#: _______________________
Physician Address: ________________________________________ Phone#: ____________________ Fax #: _________________________
I herby certify that the services in the above order form are medically necessary.
Physician Signature: _____________________________________________________________________ Date: ______________
Time: _____________
FAX Orders to: 404.501.1874
Phone: 404.501.5590
Ext 1 - Surgeons only, Ext 2 - Scheduling
SURGERY
ORDER FORM
DMC FORM # PS-1059 (10/21/14)

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