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  • $TT Melnonnrcare.: Radiorosy ?Lfff8Xu?R

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    TylerNguyen
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    This document authorizes medical imaging tests for a patient named Tom Nguyen. It approves a CT scan of the chest and pelvis to evaluate mitral valve disorders. The referral is from Dr. Arfa Babaknia and the tests will be performed at Newport Diagnostic Center. The authorization is valid from July 19, 2012 to October 17, 2012. Payment for the services should be sent to Memorial Care Medical Foundation.

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    This document authorizes medical imaging tests for a patient named Tom Nguyen. It approves a CT scan of the chest and pelvis to evaluate mitral valve disorders. The referral is from Dr. Arfa Babaknia and the tests will be performed at Newport Diagnostic Center. The authorization is valid from July 19, 2012 to October 17, 2012. Payment for the services should be sent to Memorial Care Medical Foundation.

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    6 views1 page

    $TT Melnonnrcare.: Radiorosy ?Lfff8Xu?R

    Uploaded by

    TylerNguyen
    This document authorizes medical imaging tests for a patient named Tom Nguyen. It approves a CT scan of the chest and pelvis to evaluate mitral valve disorders. The referral is from Dr. Arfa Babaknia and the tests will be performed at Newport Diagnostic Center. The authorization is valid from July 19, 2012 to October 17, 2012. Payment for the services should be sent to Memorial Care Medical Foundation.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
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    of 1

    +Wsw^ $tt MElnonnrCARE.

    tlF Mrucnr Gnoup


    Referral/Outside Testing Ancillary
    This authorization validfor the datesindicated the memberpro/es to be benefiteligible the time servicesare rendered. is if at ProMder responsible eligibility copayrnent is for / verification. Applicable copayment be deducted will from claimsreimbursement.

    Auth/Ref# 2190766 NGUYEN, TOMD 9175 CROCUS AVE FOUNTAIN VALLEY 92708 CA. SEX DOB HOME# MEDREC# sEe# M 11t15t1958 (714)596-3404 802623 FM)271-1244

    Valid: 711912012 Care - 1011712012 Insurance:California Status: AppROVED Member 22545601 0 lD: 9-1
    Refer From: BABAKNIA, ARFA 11420 WARNER AVE FOUNTAIN VALLEY 92708 CA, (714) Phone: 5491300 Fax:(714\665-4623 NPI:1205826849 ReferTo: NEWPORT DIAGNOSTIC CTR. NEWPORT (NB) DtAGNOSTtc CENTER 1605AVOCADO AVE NEWPORT BEACH CA.92660 (949)760-3025 Phone: Fax (949)720-394

    424.0 Procedure 71275 72191

    MITMLVALVE DISORDERS ' Modifier Units Description CTANGIOGRAPHY, CHEST 1 CTANGIOGMPH WO&WDYE PELV 1

    Status APPROVED APPROVED

    Unless noted doesnotinclude this majorsurgery hospitalization. services prior, or These mustreceive separate authorization, THEREFERRAL SPECIALIST MMED ABOVE AN INDEPENDENT IS CONTRACTORAND NOTA MEMORIALCARE MEDICAL GROUP A MEMORIALCARE OR MEDICAL FOUNDATION EMPLOYEE ORAGENT. spEctALTy(s) FOR PAYMENT, SEND STATEMENT TO: Memorial Care Medical Foundation

    Radiorosy

    ?lfff8xu?r,
    mcruz8 Prepared Date: 0711912012

    AuthorizedBy: Prepared By:


    Comments\Nob

    BABAKNIA, ARFA

    <071I9120L2 j mcruzS> 03:08 ***ASAP*** cTANGIOAORTAW CONTMSTW RECONSTRUCnON 3D DX:MITMLVALVE , DISORDER CC:DRBETHANCOURT 562-42+L228 FAX

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    patient rorropriate tetter


    MemorialCare MedicalGroupprwides professional seMces exclusively behalfof MemorialCare on MedicalFoundation

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