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CARONDELET HEALTH NETWORK
A MEMBER
OF
ASCENSION HEALTH
F AC S I M I L E T R AN S M I T T A L S H E E T
DATE:
TO: ROBIN MARCELLO/ERIKA GONZALEZ/LISA
SALCIDO
FROM:
TO FAX NUMBER: 520-872-7884
FROM FAX NUMBER:
TO COMPANY: CENTRALIZED SCHEDULING
FROM COMPANY:
TO PHONE NUMBER: 520-872-7200
FROM PHONE NUMBER:
RE:
TOTAL PAGES INCLUDING COVER:
PR IOR AUTH OR IZA TION:
The authorization team is available to assist with getting most
authorizations.
Would you like the authorization team to obtain prior Authorization?
Yes No
NOTES / COMMENTS:
CONFIDENTIALITY STATEMENT
The information contained in this fax document may be privileged, confidential, and protected under applicable law and is
intended solely for the use of the individual or entity to which it is addressed. If you are not the intended recipient,
employee, or agent responsible for delivering the message to the intended recipient, you are hereby notified that any
dissemination, distribution, or copying of this communication is strictly prohibited. If you have received this
communication in error, please notify the sender immediately at the number listed below, and destroy the document.
Thank You.
CARONDELET HEALTH NETWORK
A MEMBER
OF
ASCENSION HEALTH
The following paper work needed to complete your request:
 All clinical history and progress notes
 Physician NPI
 Valid contact number for patient and or demographic sheet
 Copy of insurance card front and back (if applicable)
 Order with Diagnosis (ICD 9) and Procedure (CPT). Please list codes if available.
Please note:
 If order is received at 2pm business day; process will not begin till next business day.
 Please be aware that if you would like to assist with an authorization, the patient will be
scheduled 5 days out to allow enough time for us to obtain the authorization.
 In order to expedite all STAT cases, authorizations must be provided at time of scheduling. Due to
urgent nature, we are unable to assist with authorizations for STAT cases.
 All STAT’s must be called in to schedule.
 We will contact patient if any of the information below is not filled out.
DO NOT HAVE TO FILL OUT IF CONTACT INFORMATION OR DEMOGRAPHIC SHEET IS SENT!
First Name:
Middle Initial:
Last name:
DOB:
Contact number:
(if applicable) Patient Preference (day of the week, time of day and facility):
(if applicable) If copies of report needs to be sent to additional physicians, please provide full name:
(IF ABLE & APPLICABLE) Information needed for specific types of exams:
CT
i.
Any known Allergies to dyes?  Yes No
ii.
Is patient 75 or older?  Yes  No If yes, we need current (within 90 days) creatinine levels.
iii.
Is patient diabetic?  Yes  No
a.
If yes, if patient is taking metformin, glucophage, or glucovance- they must stop taking medications for 48
hours after the exam; We will need current (within 90 days) creatinine levels.
iv.
Any history of kidney disease or dialysis or CHF?  Yes  No
a.
If yes, we need current (within 90 days) creatinine levels.
What was the first day of last menstrual period? ____________________________________________________________
v.
MRI
i.
Any metal in the body?
Pacemaker  Yes  No Aneurysm clips  yes  No Cardiac valve replacements  yes No
Stimulators  Yes  No  Other: ___________________________________________________________________
ii.
What was the first day of last menstrual period? ____________________________________________________________
iii.
Claustrophobic?  Yes  No if yes, will sedation be provided?  Yes  No
Please note: sedation must be provided by physician.
iv.
Any history of kidney disease or dialysis or CHF? Yes  No If history of kidney disease, we will need current (90
days) creatinine levels.
Abdominal Ultrasound
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CARONDELET HEALTH NETWORK
A MEMBER
i.
OF
ASCENSION HEALTH
Is patient able to fast?  Yes  No if patient has any problems with fasting we will schedule the exam in the early
morning.
Dexa
ii.
Any metal plates, rods, or pins in the lower back or hip area?
 Yes  No If yes, explain:
iii.
Any previous exams, with contrast, within 7 days prior to appointments date?  Yes No
(If able and applicable) Additional information needed for exams:
iv.
Patients Height and weight.________________________________________________________________
v.
Any special needs (i.e. Wheelchair, crutches, canes, mentally handicapped, vision impaired, Needs interpreter, IV tubing,
catheters?
a.
If yes, explain: __________________________________________________________________
Please note: if patient requires lifting he or she will be scheduled at the hospital.
_________________________________________________________________________________________
We do not schedule:
*We do not have an open MRI*
List of facilities:
SMIC
395 N. Silverbell Road, Suite 185
520-872-6900
CIC
630 N. Alvernon Way
520-873-3288
GVIC
400 W. Camino Casa Verde
520-872-4555
RR
8290 S. Houghton Rd.
520-873-3100
CSJ Hospital
350 N. Wilmot Rd.
520-873-3000
CSM Hospital
1601 W. St. Mary’s Rd.
520-872-3000
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