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CI | Visotsky Surgical Request

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Step 1 of 7 - Schedule Information

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  • Schedule Information

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  • Next - Surgical Information

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  • Surgical Information

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  • Next - Patient Information

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  • Patient Information

  • Use 9999 if N/A
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  • ISMOSC - BMI
  • Contact Information

  • Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 100 MB.
    Both front and back must be present in the same file.
    Use formats: jpg, jpeg, gif, png, pdf
  • Next - Primary Insurance Information

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  • Primary Insurance Information

  • Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 100 MB.
    Both front and back must be present in the same file.
    Use formats: jpg, jpeg, gif, png, pdf
  • MM slash DD slash YYYY
  • Next - Secondary Insurance Information

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  • Secondary Insurance Information

  • Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 100 MB.
    Both front and back must be present in the same file.
    Use formats: jpg, jpeg, gif, png, pdf
  • MM slash DD slash YYYY
  • Next - CPT & ICD9/ICD10 Codes

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  • CPT Codes

  • ICD10 Codes

  • Next - Content Submission

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  • Content Submission

  • Please type Yes or No
  • If you have chosen to upload patient files with this request.

    PLEASE ALLOW FILES TO UPLOAD. PLEASE REFRAIN FROM HITTING THE FORM SUBMISSION BUTTON MORE THAN ONCE.
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