Surgery Reservation Request

Step 1 of 7

Facility & OR Location

Facility Name

OR Name

Options are limited to the OR/procedure areas at the selected facility.

Step 2 of 7

Patient Information

Patient Name

Date of Birth

Social Security Number

Format: ###-##-####

Phone Number

Secondary Phone Number

Insurance Plan Name

Insurance Plan Number

Medicare or Medicare Advantage plan?

Yes No

Use Current Insurance

Yes No

Use the insurance currently on file in the patient record.

Bill to study?

Yes No

Pre-paid Cosmetic Case?

Yes No

Step 3 of 7

Case Information

Referring Provider

Referring Provider Phone #

Case Classification

STATEmergentWithin 24 hoursNext Day or Future

Requested Procedure Date

Alternative Date

Requested Time

Format: HH:MM AM/PM

Case Requested By

Name and role of the person submitting the request.

Patient Class

OutpatientInpatient

Post Op Destination

Discharge23 hour stayAdmit - Med/SurgAdmit - ICU

Admission Source

HomeAdmittedLong Term CareOther

Request Type

ScheduleRescheduleCancellation

Carried from the current 2026 form so this electronic version replaces it cleanly.

Step 4 of 7

Provider Information

Admitting Physician

Assisting Physician

Total Expected Time (in minutes)

Whole minutes, e.g. 120

Attending Physician (if different than admitting)

Step 5 of 7

Procedure

Primary Dx Code and Description *

ICD-10 code with description, e.g. K35.80 - Acute appendicitis

CPT Code(s) for All Planned Procedures *

0 / 2000

List one CPT code per line. Include modifiers if applicable.

Procedure Name

Procedure Description

0 / 2000

Laterality

LeftRightBilateralN/A

Region of Body

Combo Case (multiple services)

Yes No

Implant Information (if applicable)

0 / 2000

Include vendor, sizers/expanders. Order list must be submitted same day as scheduling request.

Chemotherapy Drug Information (if applicable)

0 / 2000

Additional Notes / Special Considerations

0 / 2000

Step 6 of 7

Scheduling Information

Does patient need coordination with a procedural appointment (endoscopy, radiology)?

Yes No

Billing Type

Standard / InsuranceFully CosmeticPartially CosmeticOther Billing Consideration

Does patient have a latex allergy?

Yes No

Other Allergies

0 / 2000

List any other allergies including drug, environmental, food.

How early should the patient arrive?

Example: 90 minutes before scheduled start

Interpreter needed?

Yes No

Special Requests - Details

0 / 2000

If 'Equipment' or 'Supplies' is selected, list specific items here.

Insurance Authorization Code

Step 7 of 7

Submitter & Confirmation

Your Name

Your Role

Example: Surgical Coordinator, Office Manager, RN.

Your Email (for confirmation)

Confirmation copy of the submission will be sent here.

Your Phone (for follow-up)

Final step

Review & Submit

Confirm the information below. Click any section's Edit link to make changes before submitting.