1500 Forest Glen Road
Silver Spring, MD 20910-1484
Phone: (301) 754-7255
Fax: (301) 754-7263
www.holycrosshealth.org
Surgical Scheduling Form – Elective Surgery
Please fax the completed form to (301) 754-7263.
Procedure Information:
Request date and time for procedure in order of preference a) ______________ b) ______________ c) ______________
Procedure Name (exact name from procedures list): ___________________________________________________________
Procedure Description___________________________________________________________________________________
Length of Procedure: _________________________________________
Patient Name: (Patient identified legal name, usually on driver’s license)
Last Name: _____________________________________ First Name: _______________________________________________
Date of Birth: _____________________ SS#____________________ Gender:  Male  Female  Unknown
Address: Street__________________ City__________________ State___________ Zip_____________
Phone Number______________________________ Alternative Phone ________________________
Primary Care Physician__________________ Physician’s Phone Number ________________
Surgeon Name_________________________ Surgeon’s Phone Number ________________
Procedure Details: Check One:
 SS Surgical Services
 SS Main OR
Name:
 SS Kaiser Services
 SS Endo
 Ambulatory Surgery
 Yes
 Inpatient
 No
 Yes
 Yes
 Yes
Name:
Authorization No.
Name:
Authorization No.
 Yes
No.
 No
 No
 No
ID:
 No
 Unknown
 Yes
 Yes
 Yes
 Yes
 Yes
If yes: What language(s)?
 No
 No
 No
 No
 No
 Unknown
 Unknown
 Unknown
 Unknown
 Unknown
Will Pre-Admission Testing Be Done at Holy Cross?
 Yes
If No: Where will it be done?
 No
 Unknown
Frozen Section Requested
Laser Requested
Implant
Special Equipment / Critical Items:
 Yes
 Yes
 Yes
 No
 No
 No
 Unknown
 Unknown
 Unknown
Appointment Type:
Appointment Location
Assisting Surgeon
Registration Diagnosis
Surgery Diagnosis
Admission Type:
Day of Surgery Admit?
Anticipated Post Op Floor Destination
Add On?
Patient Has Medicare?
Patient Is a Self-Pay?
Primary Insurance
Secondary Insurance (if applicable)
Workers Compensation (if applicable)
CPT 4 Code
Diagnosis (ICD-9-CM)
Do you need a PA?
Do you need CArm/Xray?
Do you need a Cell Saver?
Do you need Ultrasound?
Is Interpreter Required?
 Unknown
ID:
Holy Cross. A New Generation of Medicine .TM
1500 Forest Glen Road
Silver Spring, MD 20910-1484
Phone: (301) 754-7255
Fax: (301) 754-7263
www.holycrosshealth.org
Comments / Special Patient Needs (example: patient deaf, patient from nursing home, name of parents for a child):
*More detail information for Mammo / US / Nuclear Med with OR Procedures
Reason for exam:
Patient has previous films?
Patient has latex allergy?
Radiologist needed?
Physician order status:
 Yes. Where?
 Yes
 Yes
 No
 No
 No
 Unknown
 Unknown
 Unknown
Mammo procedure: Patient had a previous mammo?
Mammo procedure: Patient has lump and/or implant?
 Yes
 Yes
 No
 No
 Unknown
 Unknown
Confirmation:
Procedure:
Patient’s FIN:
Case Number:
Surgical Scheduler Name:
Date:
Time:
Please fax the completed form to (301) 754-7263.
Holy Cross. A New Generation of Medicine .TM
Revised October 2012