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CI | Visotsky Surgical Request

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Step 1 of 7 - Schedule Information

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  • Schedule Information

  • MM slash DD slash YYYY
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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

    You will be able to upload all files before you submit your form.
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    Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 24 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

    You will be able to upload all files before you submit your form.
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    Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 24 MB.
    Both front and back must be present in the same file.
    Use formats: jpg, jpeg, gif, png, pdf
  • This will assist us in identifying uploaded files.
  • MM slash DD slash YYYY
  • Next - Secondary Insurance Information

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  • Secondary Insurance Information

    You will be able to upload all files before you submit your form.
  • Hidden
    Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 24 MB.
    Both front and back must be present in the same file.
    Use formats: jpg, jpeg, gif, png, pdf
  • This will assist us in identifying uploaded files.
  • 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.
  • Drop files here or
    Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 24 MB.
      If uploading an ID or Insurance Card Both front and back must be present in the same file.
      Use formats: jpg, jpeg, gif, png, pdf
    Save and Continue Later

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