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Fax cover sheet

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
The information contained in this fax document may be privileged, confidential, and protected under applicable law and is intended solely for the use of the individual or entity to which it is addressed. If you are not the intended recipient, employee, or agent responsible for delivering the message to the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this communication in error, please notify the sender immediately at the number listed below, and destroy the document. Thank You. 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

Source: http://www.carondelet.org/Portals/0/docs/breast-center/Prior%20Authorization%20Assistance%20Form.pdf