Fillable ASC OR BOOKING SHEET PHONE # 444-9431 FAX (Academic medical center at State University of New York at Stony Brook)

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ASC OR BOOKING SHEET PHONE # 444-9431 FAX (Academic medical center at State University of New York at Stony Brook)

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BROWSE ACADEMIC MEDICAL CENTER AT STATE UNIVERSITY OF NEW YORK AT STONY BROOK FORMS

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ASC OR BOOKING SHEET PHONE # 444-9431 FAX # 444-6452
* Patient’s Contact phone day before surgery_____________________________
PATIENT NAME_________________________________________ DOB_______________ SS#______________________
MRN__________________HOME PHONE________________________ WORK /CELL___________________________
INSURANCE____________________________________AUTH/ REFFERAL#___________________________________
DATE OF SURGERY __________________ PHYSICIAN________________________________________SVC________
PHYSICIAN’S CONTACT PERSON & PHONE__________________________________________________________
CPT CODE SURGEON’S PROCEDURE SITE/ SIDE
___________ ____________________________________________________________________________ ____________
___________ ____________________________________________________________________________ ____________
___________ ____________________________________________________________________________ ____________
SBUMC PROCEDURE: ___________________________________________________________________________________
_______________________________________________________________________________________________________
ICD9 CODE(S) :
________________________________________ DURATION OF SURGERY : _____________ HR(S)
CHECK THAT ALL APPLY :
XRAY NEEDED LATEX Has Pacemaker
DURING SURGERY _______ ALLERGY_______ Pace/Defibrillator ________DIABETIC________PREGNANT_______
COMMENTS/MISCELLANEOUS
SPECIAL EQUIPMENT/IMPLANTS NEEDED FOR PROCEDURE : ________________________________________
______________________________________________________________________________________________________
BREAST SIZERS NEEDED ?
________ **REQUIRED FOR ALL BREAST CASES**
DOES PATIENT NEED POS APPOINTMENT AT SBUMC? YES NO
ASA________**ANESTHESIA CONSULT REQUIRED FOR ADULT PATIENT ASA 3 OR PATIENT LESS THAN 18 YEARS ASA 2 OR 3
POS SERVICES NEEDED: PLEASE CHECK THOSE THAT APPLY – FOR SCHEDULING PURPOSES ONLY
**PHYSICIANS MUST USE APPROPRIATE HOSPITAL FORMS FOR ORDERS* * PLEASE FAX ALL TESTING ORDERS TO 444-9536*
POS COMMENTS
ANESTHESIA
CONSULT_____________EKG____________H & P___________LABS___________
Is this patient either residing in a facility or group home, mentally disabled or on a ventilator?
If yes, provide details__________________________________________________________________________________
Office use only
OR SCHEDULED________________________ FAX_________ POS SCHEDULED _________________________PREREG_______
CO-PAY/ DEPOSIT/ DEDUCTIBLE_____________BY_____________FINANCIAL APPROVAL AND COMMENTS_
_____________________________________
REV 11-08-10
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ASC OR BOOKING SHEET PHONE 444-9431 FAX (Academic medical center at State University of New York at Stony Brook)

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Completed 27 August 2020

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