Get Citrus Valley Health Partners Gi Scheduling Form Campus: Fph (fax: 6268573109) Ich (fax

Filling out the Citrus Valley Health Partners GI Scheduling Form is essential for scheduling medical procedures efficiently. This guide offers clear steps to help you complete the form accurately and ensure that all necessary information is included for smooth scheduling.

Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to acquire the Citrus Valley Health Partners GI Scheduling Form, opening it in your preferred editor.
2. In the 'Procedure Information' section, specify the procedure date in the 'mm/dd/yy' format, then enter the start time using the 'hh:mm' format. Select whether the estimated length is AM or PM.
3. Identify the physician's name and select the procedure type from the options provided (e.g., EGD, Colonoscopy, etc.). If necessary, provide the CPT codes for the procedure.
4. In the 'Diagnosis' field, write out the diagnosis in full, avoiding any abbreviations. Provide the corresponding ICD-10 codes.
5. Choose the type of anesthesia by selecting one option, such as 'Moderate Sedation' or 'Anesthesiologist Required.' Include any special considerations like allergies or isolation requirements.
6. Fill out the 'Patient Information' section, including the patient's first name, last name, date of birth, gender, and primary language spoken. Ensure to also enter the primary and secondary phone numbers.
7. Provide the patient's address type, including options like 'Home' or 'Long-term Care Facility,' and fill in the street, city, state, and zip code.
8. Record the primary care physician's name and include their phone number.
9. In the 'Insurance & Admission Information' section, fill in the insurance provider name, policy number, and insurance ID. Specify the admission type and include the authorization number.
10. Complete the 'Supply and Equipment Information' by indicating if C-ARM/Fluoroscopy is needed. Note any additional special equipment or requests.
11. In the 'Completion Information' section, provide the name of the person completing the form, their phone number, and date. Include the fax number to which the form will be sent.
12. Once all fields are filled out accurately, save your changes, download, print, or share the completed form as needed.

Complete the Citrus Valley Health Partners GI Scheduling Form online for a seamless scheduling experience.