• Encino Children's Surgical Posting Request Form

  • Date Submitted
     / /

  • Patient Information

  • Patient's Date of Birth*
     - -
  • Gender*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Primary Language

  • Surgical Information

  • Requested Surgery Date
     / /
  • Principal Diagnosis*
  • Medical Necessity (used for medical pre-authorization)*

  • Primary Dental Insurance

  • Subscriber's Date of Birth
     - -
  • Format: (000) 000-0000.

  • Secondary Dental Insurance

  • Does the patient have secondary dental insurance?*
  • Secondary Subscriber's Date of Birth
     - -
  • Format: (000) 000-0000.

  • Primary Medical Insurance

  • Subscriber's Date of Birth
     - -
  • Format: (000) 000-0000.

  • Secondary Medical Insurance

  • Does the patient have secondary medical insurance?*
  • Secondary Subscriber's Date of Birth*
     - -
  • Format: (000) 000-0000.

  • 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
  • Date of Illness
     - -
  • Surgical History?
  • Adverse Reaction to Previous Anesthetic (patient or blood relative)?
  • Medical Conditions*
  • Format: (000) 000-0000.
  • H&P appointment date
     / /

  • Patient Education

  • Preadmission Preparation*

  • Attachments

  • Please upload all documentation requested below (select the boxes next to each to confirm that the file has been uploaded)*
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  • To help ensure timely scheduling for your patients, please submit complete posting sheets with all required documentation attached.

    Incomplete submissions will be returned for completion.

  •  

  • Please download a copy of the posting sheet for your records before you click submit.

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