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Unc.edu UNC Endoscopy Center at Meadowmont 300 Meadowmont Village Circle Suite 335 Phone 919 843-7200 Fax 919 843-7136 GI Procedures Order Form MIM 1224 Please provide the information requested and return via fax. EGD Colonoscopy Upper EUS Flexible Sigmoidoscopy Lower EUS Capsule Endoscopy ERCP Ileoscopy Push Enteroscopy Infra-Red Coagulation IRC of Hemorrhoids Deep Enteroscopy Pouch Exam Other Advanced procedures that are only performed at UNC Memorial Hospital and will only be scheduled after a GI physician reviews relevant notes labs pathology and imaging reports if not on webCIS. Please fax these records to 919-966-8764. Performed at Meadowmont only Indication for the procedure s For screening or surveillance colonoscopy Date of last procedure Where Special Request or instructions I certify that the diagnosis provided support the tests ordered and are medically necessary. UNC GI Procedures at UNC Hospitals 101 Manning Drive Chapel Hill NC Chapel Hill NC 27514 Phone 919 966-2310 Fax 919 966-8764 scheGIHO unch. For a pre-procedure clinic consultation call 919 966-6000. Patient Information First Name Last Name UNC Birth Date Home phone Work/other phone Medicare will only pay for services that it determines to be reasonable and necessary under section 1862 a 1 of the Medicare Law. When ordering tests for which Medicare reimbursement will be sought physicians should order only those individual tests that are necessary for the diagnosis and treatment of a patient rather than for screening purposes. EGD Colonoscopy Upper EUS Flexible Sigmoidoscopy Lower EUS Capsule Endoscopy ERCP Ileoscopy Push Enteroscopy Infra-Red Coagulation IRC of Hemorrhoids Deep Enteroscopy Pouch Exam Other Advanced procedures that are only performed at UNC Memorial Hospital and will only be scheduled after a GI physician reviews relevant notes labs pathology and imaging reports if not on webCIS. Please fax these records to 919-966-8764. Performed at Meadowmont only Indication for the procedure s For screening or surveillance colonoscopy Date of last procedure Where Special Request or instructions I certify that the diagnosis provided support the tests ordered and are medically necessary. Requesting MD Signature ID Date MD Name please print Phone Fax We are here to assist you. If you have any questions please call 919-966-5563 PROCEDURE SCHEDULED Date / / Chart Location Provider Orders Time. For a pre-procedure clinic consultation call 919 966-6000. Patient Information First Name Last Name UNC Birth Date Home phone Work/other phone Medicare will only pay for services that it determines to be reasonable and necessary under section 1862 a 1 of the Medicare Law. When ordering tests for which Medicare reimbursement will be sought physicians should order only those individual tests that are necessary for the diagnosis and treatment of a patient rather than for screening purposes. When ordering tests for which Medicare reimbursement will be sought physicians should order only those individual tests that are necessary for the diagnosis and treatment of a patient rather than for screening purposes. EGD Colonoscopy Upper EUS Flexible Sigmoidoscopy Lower EUS Capsule Endoscopy ERCP Ileoscopy Push Enteroscopy Infra-Red Coagulation IRC of Hemorrhoids Deep Enteroscopy Pouch Exam Other Advanced procedures that are only performed at UNC Memorial Hospital and will only be scheduled after a GI physician reviews relevant notes labs pathology and imaging reports if not on webCIS.