Andrew Women's Hospital

AWH OB Procedure and GYN Surgical Scheduling Request Form

Baylor Scott & White Medical Center - Andrew Womens Hospital

OR Scheduline Phone: (817) 698-8613

Fax: (817) 698-8611

Email: basandrewswomensorscheduling@BSWHealth.org

Requestor Name

Phone Number

Fax Number

Email Address

Patient Information

Please send scans of patient's driver's license

Last Name

First Name

Middle Initial

Birth Date

Weight

Weight Metric

Gender

Primary Phone

Alternate Phone

Address

Language interpreter needed, incl. sign language

Insurance Information

Scan and e-mail a copy of patient's identification and insurance card (front & back)

Primary Insurance

Insurance Phone

Subscriber Nmae

ID #

Group

Has Secondary Insurance

Procedure Information

1st Scheduling Option

Start Time

Length of Procedure

2nd Scheduling Option

Start Time

Length of Procedure

Surgeon's Last Name

Surgeon's First Name

Secondary Surgeon / 1st Assist

Type of Anesthesia

Preference Card #

ICD Code

Diagnosis

CPT Code

Laterality

Procedure Description (No abbreviations)

C-Arm

Notes

Starting Position

Vendor requested for case coverage (Equipment, Company, Rep, Phone No.):

Latex Allergy

Patient has heart device

Blood/blood product needed? (For planning purpose only)

Patient or Family History of Malignant Hyperthermia

Procedure Type

Gynecological Pre-Admit Testing Information

Best phone number for PAT to call patient

Advise your patient they will get a phone call from your Pre-Admission testing Nurse. Please pay attention to your voice mail messages.

Please inform your patient of:

Registration will call to discuss demographic data, insurance benefits, and the patient's estimated financial responsibility. Tell the patient the call will come from (844) 211-1790, please consider saving this number as BSW Registration until after your procedure is completed.

Pre- Admission Testing will call to discuss medical history, day of surgery paperwork and any necessary lab tests. Tell the patient the call will come from (817) 698-8789 or (817) 698-8790, please consider saving this number as AWH Pre Admission Testing until after your procedure is completed.

Obstetrics Procedure Detail

Obstetrics - Pre Admit Testing Information

Best phone number for ATC to call patient

Advise your patient they may get a call from the ATC Nurse. Please consider saving this phone number in your contacts until delivery is completed, 817-698-8442. If you have not registered your pregnancy, please do so today.

Please inform your patient of:

Final Provider Requirements

Day of Surgery orders, current H&P and chart documents must be faxed to 817-698-8611 at least 48 hours prior to the procedure for them to be available to the Physicians and Nurses in our EMR.

Postop Bed Planning

Patient Class

Location

ICU Bed

Has patient been admitted in last 30 days to any BSWH Hospital

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AWH OB Procedure and GYN Surgical Scheduling Request Form

Baylor Scott & White Medical Center - Andrew Womens Hospital

Obstetrics - Pre Admit Testing Information

Final Provider Requirements