2024 State Trooper Surgeons Medical Options Request

EXECUTIVE CARE INTAKE FORM

State Trooper Surgeons Medical Options Request
Please provide the information requested below.

THE INFORMATION ENTERED BELOW SHOULD BE FOR THE PERSON WHO IS IN NEED OF CARE.

Once submitted, you will be contacted the same business day.
1) Name *

First NameMiddle NameLast NameSuffix
2) Rank or Title (Ex. BCI, Trooper, Sgt etc. OR Spouse/Family Member of Trooper)
2a) If you are a family member, please provide the name of the Trooper
3) Troop*

ABCDEFG/HKNYCLT
4) Date of Birth:*
5) Home Address:*
City:*
State/Zip:*
6) Phone Number*
7) Secondary Contact Person & Relationship:
Optional
8) Secondary Contact CELL Phone
9) Primary Contact E-mail Address:*
10) How far are you willing to travel?*
Ex. 30 min or 50 miles
11) CONSENT: The member has given permission for the aforementioned Primary Contact Person to represent or speak on his/her behalf. Further, permission is provided for the State Trooper Surgeons staff to speak with medical providers and their staff for the purposes of developing medical options for the medical issue outlined below:*

Yes
12) Current Treating Physician *
13) Current Physician Phone Number: *
14) Is your current physician willing to send a referral on your behalf, if needed?*
15) Insurance Carrier Name: ** If this is a Workers Comp request, skip to #17***
16) Insurance Number: ** If this is a Workers Comp request, skip to #17***
17) Worker's Compensation Claim Number (NA if not applicable):*
18) Brief Description of Medical Issue:*
19) Specific Request for Medical Assistance:*
20) EAP Referral*

YESNO
21) 9/11 First Responder

YESNO
CANCER CARE, TRANSPLANTS & INFERTILITY:

Center of Excellence Enrollment
For the Empire Plan (NYSHIP), patients should determine if the care facility of choice is listed as a Center of Excellence for the following conditions:
- Cancer Care
- Transplants
- Infertility
Patients must call 1-877-769-7447 to enroll after selecteding a listed Center of Excellence. Press or say 5 for The Empire Plan Nurseline.

The following are some of the benefits of enrollment when appropriate:
- Paid-in-full benefits including in and outpatient hospital services and physician care related to approved services.
- Travel, meal and lodging expense allowance when pre-authorized and enrolled in the Center of Excellence program.
- Other benenfits may apply. Understand more about this benefit at Empire Plan Centers of Excellence
MEDICAL RECORDS DISPOSITION:

Important: You will be required to either obtain and forward, or request your physician(s) to forward, all pertinent medical records and/or imaging to your newly selected provider prior to being seen. Please make arrangements to have your records sent upon request.
AUTHORIZATION: Submitting this form gives PBA Surgeons staff the necessary authorization to accept only the medical information you have provided on this intake form, and to forward this information to necessary medical professionals to establish medical options for your care. We remain HIPPA compliant and will not share this information with anyone without your authorization.
Should be Empty:

EXECUTIVE CARE INTAKE FORM

CANCER CARE, TRANSPLANTS & INFERTILITY: