Add procedures requests from doctors (coded)

Area *

North California

South California

Washington State

Arizona

North Carolina

South Carolina

Patient Name *

PRN (Medical Record Number from Practice Fusion) *

Preferred Surgery Center

Sesion 1: 1st Procedure *

Session 1: 1st Procedure Note *

Sesion 2: 2nd Procedure

Session 2: 2nd Procedure Note

Sesion 3: 3rd Procedure

Session 3: 3rd Procedure Note

Sesion 4: 4th Procedure

Sesion 4: 4th Procedure Note

Sesion 5: 5th Procedure

Session 5 5th Procedure Note

Is patient taking blood thinners? *

Yes

No

Provider *

Comments

Sedation *

Yes

No

Bedside Procedure? *

Yes

No

IS THIS A BIG CASE? For example: MILD, SCS, Vertiflex, Kypho, Intracept, ViaDisc *** Does it require a Psych evaluation prior the procedure approval? *

Can this procedure be performed by another provider or it has to be the referring provider? *

Referring Provider Only

Any other provider can perform this procedure

Other

Other Provider

Synergex Med - Procedures Form