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EviCore Healthcare Spine Surgery Clinical Worksheet free printable template

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SPINE SURGERY CLINICAL WORKSHEET For MONUMENT requests, please fax this completed document along with medical records, imaging, tests, etc. MEDICAL RECORDS ARE REQUIRED WITH THIS FORM. Failure to
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How to fill out evicore spine surgery

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How to fill out EviCore Healthcare Spine Surgery Clinical Worksheet

01
Gather patient information, including demographics and medical history.
02
Document the specific symptoms the patient is experiencing.
03
Review and incorporate previous diagnostic tests and imaging results.
04
Detail the conservative treatment methods that have been attempted, including dates and outcomes.
05
Indicate any relevant comorbidities or conditions that may affect the surgical intervention.
06
Clearly specify the recommended surgical procedure and its justification based on the clinical findings.
07
Ensure the worksheet is signed and dated by the healthcare provider.

Who needs EviCore Healthcare Spine Surgery Clinical Worksheet?

01
Healthcare providers referring patients for spine surgery.
02
Patients who require prior authorization for surgical procedures.
03
Insurance companies to evaluate the necessity of the surgery.
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The EviCore Healthcare Spine Surgery Clinical Worksheet is a tool used to collect clinical information that assists in the evaluation and management of spine surgery cases within the EviCore Healthcare system.
Healthcare providers, including surgeons and their administrative staff, are required to file the EviCore Healthcare Spine Surgery Clinical Worksheet when submitting requests for spine surgery prior authorization.
To fill out the EviCore Healthcare Spine Surgery Clinical Worksheet, providers must accurately complete all sections, including patient demographics, medical history, diagnostic tests, and specific clinical indications for the requested spine surgery.
The purpose of the EviCore Healthcare Spine Surgery Clinical Worksheet is to streamline the prior authorization process for spine surgeries and ensure that all necessary clinical criteria are met to facilitate appropriate patient care.
The information that must be reported includes patient information, details of the spine condition, results from imaging and diagnostic tests, previous treatments tried, and specific reasons justifying the need for surgery.
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