CCS Surgical Posting Request Form

Surgical Posting Request Form
Date Submitted

MonthDayYear
Date
Patient's Age
Patient Information
Patient's Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone Number*
Secondary Phone Number
Patient / Family Email
Patient's Legal Guardian*

First NameLast Name
Guardian's relationship to the Patient*
other
Surgical Information
Treating Dentist*

First NameLast Name
Requested Surgery Date

MonthDayYear
Time requested for treatment (minutes)
(most insurances limit surgical treatment anesthesia time to 75 minutes)
Principal Diagnosis*

K02.9 CariesK1.0 Impacted teethF43.0 Acute Stress reactionOther
Medical Necessity (used for medical pre-authorization)*

2-7 years old & treatment can't be completed in-officePatient failed conscious sedation8-17 years old & Treatment can't be completed in-office & Treatment shouldn't be delayedImpacted 3rd molarsPatient has developmental disability, psychiatric or medical conditionOther
Dental Insurance
Dental Insurance Subscriber's relationship to the Patient*
other*
Dental Insurance Subscriber's Name*

First NameLast Name
Dental Insurance Carrier*
Benefit Phone Number*
Subscriber ID #*
Subscriber's Date of Birth

MonthDayYear
Does the patient have secondary dental insurance?*

YesNo
Does the patient have secondary dental insurance?

YesNO
Secondary Dental Insurance Subscriber's relationship to the Patient*
other*
Secondary Dental Insurance Subscriber's Name*

First NameLast Name
Secondary Dental Insurance Carrier*
Secondary Benefit Phone Number*
Secondary Dental Insurance Subscriber ID#*
Secondary Subscriber's Date of Birth

MonthDayYear
Medical Insurance
Medical Insurance Subscriber's relationship to the Patient*
other*
Medical Insurance Subscriber's Name*

First NameLast Name
Medical Insurance Carrier*
Medical Insurance Benefit Phone #*
Subscriber ID #*
Subscriber's Date of Birth

MonthDayYear
Date
Does the patient have secondary medical insurance?

YesNO
Does the patient have secondary medical insurance?*

YesNo
Secondary Medical Insurance Subscriber's relationship to the Patient*
other*
Secondary Medical Insurance Subscriber's Name*

First NameLast Name
Secondary Medical Insurance Carrier*
Secondary Medical Insurance Benefit Phone #*
Please enter a valid phone number.
Secondary Subscriber ID #*
Secondary Subscriber's Date of Birth*

MonthDayYear
Date
Patient's Medical Information

Note: Patients with complicating medical conditions may be asked to obtain a Specialist Medical Clearance and may need additional time to be scheduled
Patient's Height
Patient's Weight
Patient's BMI
Allergies
Medical Conditions*

Asthma (pt must bring inhaler for surgery)AutismDown SyndromeG6PDNoneOther:
H&P appointment date

MonthDayYear
Physician's Name*
Physician's Phone #*
Preadmission Preparation*

Patient advised that visiting the Capital Children's Surgery Center is like going to the hospitalH&P discussed with guardian (H&P should be completed 2 weeks prior to surgery)
Please upload all documentation requested below (select the boxes next to each to confirm that the file has been uploaded)*

treatment plan and x-rays (for medical pre-authorization)dental insurance card (front & back)medical insurance card (front & back)letter of medical necessityparent/guardian ID
File Upload*

Cancelof
In an effort to facilitate a smooth and expedited scheduling process for your patients CCSC will not accept posting sheets that are incomplete or missing requested documentation (as listed above
Posting sheet submitted by:*

First NameLast Name
email address for submission confirmation*
example@example.com
You will have the option to download a copy of the posting sheet after you click submit.
Should be Empty:

Surgical Posting Request Form

Patient Information

Surgical Information

Dental Insurance

Medical Insurance

Patient's Medical Information