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SPINE SURGERY CLINICAL WORKSHEET For MONUMENT requests, please fax this completed document along with medical records, imaging, tests, etc., to 8006494548. MEDICAL RECORDS ARE REQUIRED WITH THIS FORM.
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To fill out evicore healthcare spine surgery, follow these steps:
02
Review the evicore healthcare spine surgery form.
03
Provide your personal information, including your name, address, date of birth, and insurance information.
04
Specify the reason for the spine surgery and provide any supporting documentation or medical reports.
05
Include the details of the surgeon who will be performing the surgery.
06
Provide information about any previous spine surgeries or related procedures.
07
Indicate any relevant medical conditions or allergies.
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Sign and date the form.
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Submit the completed evicore healthcare spine surgery form to the appropriate recipient as instructed.

Who needs evicore healthcare spine surgery?

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Evicore healthcare spine surgery may be needed by individuals who have been diagnosed with spine-related conditions or injuries, such as:
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- Herniated disc
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- Spinal stenosis
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- Degenerative disc disease
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- Scoliosis
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- Spinal fractures
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- Spinal tumors
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It is important to consult with a healthcare professional or specialist to determine if evicore healthcare spine surgery is necessary for your specific condition.
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Evicore healthcare spine surgery refers to a process or program implemented by Evicore Healthcare, designed to manage and evaluate the necessity, appropriateness, and effectiveness of spine surgery procedures to ensure optimal patient outcomes.
Healthcare providers, particularly surgeons and facilities performing spine surgeries, are typically required to file for evicore healthcare spine surgery reviews to obtain authorization for procedures.
To fill out evicore healthcare spine surgery, healthcare providers must complete specific forms provided by Evicore, detailing patient medical history, the proposed surgery, and any relevant clinical documentation to support the request.
The purpose of evicore healthcare spine surgery is to ensure that spine surgery procedures are medically necessary, appropriate, and beneficial for the patient, ultimately promoting better health outcomes and reducing unnecessary surgeries.
Information that must be reported includes patient demographics, medical history, relevant imaging results, clinical findings, and details of the proposed surgical procedure.
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