Saint Mary's Hospital Urological Surgery Scheduling Form 2012-2025 free printable template

UROLOGICAL SURGERY SCHEDULING FORM Patient Name Date of Birth Height Procedure Left Positioning Information Supine Lateral Lithotomy Vendor Equipment Right Bilateral Other Implants Please check all that apply Cystoscopy Ureteroscopy Laser X-Ray Bugbee Greenwald Rigid Homium Fluro daVinci Robot TRUS Flexible Greenlight KUB Lithoclast Special Considerations / Requests Please Fax completed form to 203-709-5106 along with Surgical Booking Form. This form is not part of the Medical Record Print 56...

How to fill out 2012 saint hospital urological surgery scheduling form

How to fill out Saint Mary's Hospital Urological Surgery Scheduling Form

1. Obtain the Saint Mary's Hospital Urological Surgery Scheduling Form from the hospital's website or front desk.
2. Fill in your personal information, including your full name, date of birth, and contact details.
3. Provide your insurance information, if applicable, including the provider name and policy number.
4. Indicate the type of urological surgery needed, including any specific details or requests from your physician.
5. Select your preferred dates and times for the surgery from the provided options.
6. Sign and date the form to confirm that all information is accurate and complete.
7. Submit the completed form via the designated method (online submission, fax, or in-person).

Who needs Saint Mary's Hospital Urological Surgery Scheduling Form?

1. Patients who require urological surgeries at Saint Mary's Hospital.
2. Medical practitioners referring patients for urological procedures.
3. Insurance representatives needing to process prior authorizations for surgery.

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What is Saint Mary's Hospital Urological Surgery Scheduling Form?

The Saint Mary's Hospital Urological Surgery Scheduling Form is a document used to schedule urological surgeries at Saint Mary's Hospital, ensuring that all necessary information is collected for the planning and execution of the procedure.

Who is required to file Saint Mary's Hospital Urological Surgery Scheduling Form?

Patients who are scheduled for urological surgery at Saint Mary's Hospital are required to file the Urological Surgery Scheduling Form, along with their healthcare provider.

How to fill out Saint Mary's Hospital Urological Surgery Scheduling Form?

To fill out the Saint Mary's Hospital Urological Surgery Scheduling Form, complete all required fields with accurate patient information, medical history, and details about the planned surgery, then submit it to the hospital's scheduling department.

What is the purpose of Saint Mary's Hospital Urological Surgery Scheduling Form?

The purpose of the Saint Mary's Hospital Urological Surgery Scheduling Form is to facilitate the efficient scheduling of surgical procedures, ensuring that all necessary preparations and resources are in place for the surgery.

What information must be reported on Saint Mary's Hospital Urological Surgery Scheduling Form?

The information that must be reported on the Saint Mary's Hospital Urological Surgery Scheduling Form includes patient personal details, insurance information, medical history, specific details about the urological procedure, and any other relevant medical documentation.