MCSC 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*
Primary Language

EnglishSpanishOther
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)*

2-6 yo with multiple extractions or multiple restorations that can't be completed in officePatient is extremely uncooperative, fearful, unmanageable, anxious, or uncommunicative, with dental needs of such magnitude that treatment should not be postponed or deferred. Lack of treatment can be expected to result in dental or oral pain, infection, loss of teeth, or other increased oral or dental morbidity.Pt has physical, intellectual, or medical conditions AND dental treatment under local anesthesia is expected to be unsuccessful. Examples: mental retardation, cerebral palsy, epilepsy, and hyperactivity. (verified by appropriate medical documentation).Patient has six (6) or more teeth requiring extraction in various quadrants.Pt has dental treatment needs for which local anesthesia is ineffective due to acute infection, anatomic variation, or allergy.Other
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 Motown 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 MCSC 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