CNA

Referring Provider Information:

Referral Information:

Order Name: COLONOSCOPY

Diagnosis: Screening for malignant neoplasm of colon (Z12.11) CPT Code:

Scheduling Instructions:

Scheduled Procedure Date: 6/24/2022

Scheduled Procedure Time: 10:15 AM

Scheduled Procedure Location: ULP Abraham Flexner

Scheduled Procedure Comments: patient scheduled for COLONOSCOPY on 6/24/22 at 10:15am, arrival time 8:15am. COVID test scheduled on 6/20/22

What is the patient's sedation requirement? Anesthesia Is this procedure being added after the exam began? No Indication: Screening and Surveillance for Personal High-Risk colon neoplasia: Personal Hx colon adenoma or serrated polyp ASA Class: 2: Mild systemic disease

Pre-Anesthesia Testing Needed? No

Prep: Colyte

Blood Thinners: None

Ordered by: STOCKER, ABIGAIL

Electronically Signed and Authorized by: Abigail Stocker, MD NPI: 109******* UofL Physicians - GI Motility Clinic

225 Abraham Flexner Way Ste 502

Louisville KY 40202

Phone: 502-***-****

Fax: 502-***-****

Order Date: Nov 4,

2021

Legal Name: Peggy Peyton McMillen MRN: 400*******

102B CAROLINA CT

ELIZABETHTOWN KY 42701-3237

DOB: 7/30/1962

SSN: ***-**-****

Phone: 502-***-**** Sex: F

INSURANCE PAYOR PLAN GROUP # SUBSCRIBER ID

Primary:

MOLINA PASSPORT 11000105 000*******

STOCKER, ABIGAIL Phone: 502-***-**** Fax: 502-***-****

# Visits: 1 Referral Type: Consultation [3]

Urgency: Routine Referral Reason:

Start Date: Nov 4, 2021 End Date: To be determined by Insurer This document serves as a request of services and does not constitute Insurance authorization or approval of services. To determine eligibility, please contact the members Insurance carrier to verify and review coverage. If you have medical questions regarding this request for services. Please contact UofL Physicians - GI Motility Clinic at 502-***-**** between the hours of 8:00am - 5:00pm

(Mon-Fri).

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