To submit the Surgery Scheduling Form, attach all required documents including surgical consent, admitting orders, and a copy of the insurance card. Fax the completed form to (509) 751-4568 or call (509) 758-4661 for any assistance. Alternatively, you can email the form or submit it through an online submission portal if provided by Tri-State Memorial Hospital. Ensure all information is accurate to avoid any delays. My advice is to double-check all entries before submission and confirm receipt with the hospital to ensure your surgery is scheduled without any issues.

The Surgery Scheduling Form should be submitted well in advance of the surgery date. Ensure all information is accurate and complete to avoid delays.

The purpose of the Tri-State Memorial Hospital Surgery Scheduling Form is to streamline the process of scheduling surgeries. By gathering all necessary patient information, surgical details, and insurance information in one place, the form ensures that all parties involved have the information they need to provide the best possible care. Properly completing this form helps to avoid any delays or issues that could arise from missing or incorrect information.

• 1. Patient Name: The full name of the patient undergoing surgery.
• 2. Patient Address: The residential address of the patient.
• 3. Guarantor: The person responsible for the patient's medical bills.
• 4. Procedure/Surgery Date: The date when the surgery is scheduled to take place.
• 5. Description: A brief description of the surgical procedure.
• 6. Date of Birth: The patient's date of birth.
• 7. Phone Number(s): Contact phone numbers for the patient.
• 8. Best Time to Call for Pre-Op Appointment: The most convenient time to contact the patient for their pre-operative appointment.
• 9. Inpatient/Outpatient: Indicates whether the surgery will be inpatient or outpatient.
• 10. Post/Follow Up Appointment: The date and time for the patient's follow-up appointment after surgery.
• 11. Procedure Code(s): Medical codes associated with the surgical procedure.
• 12. Attending Physician(s): Name of the physician(s) attending to the patient during surgery.
• 13. Primary Care Physician: The patient's primary care physician.
• 14. Diagnosis Code(s): Medical codes related to the patient's diagnosis.
• 15. Insurance: Details of the patient's insurance information.
• 16. Subscriber Name: Name of the insurance subscriber.
• 17. Insurance Phone: Contact phone number for the insurance company.
• 18. Prior Authorization: Information on whether prior authorization has been obtained and the authorization number.
• 19. Contact Person at Insurance Company: The name of the contact person at the insurance company.
• 20. Policy #: The insurance policy number.
• 21. Group #: The insurance group number.
• 22. Relationship: The relationship of the patient to the insurance subscriber.
• 23. Number of Days Approved: The number of days approved for the patient's hospital stay.

Failure to submit the form may result in delays in scheduling the surgery. It is crucial to complete and submit the form accurately to avoid complications.

• Delay in Surgery: The surgery may be postponed due to incomplete or missing information.
• Insurance Issues: Authorization and coverage may be affected, leading to potential financial complications.
• Patient Care: Important medical information may be overlooked, impacting the quality of care provided.

• 1. Surgery Scheduling: Essential for booking and documenting surgical procedures.
• 2. Insurance Authorization: Required for obtaining insurance authorization for the surgery.
• 3. Pre-Op Planning: Helps in planning and coordinating pre-operative appointments.
• 4. Medical Information: Ensures that all relevant medical and patient information is collected.
• 5. Post-Op Follow-Up: Schedules necessary follow-up appointments after surgery.