Provider Request Sheet s1

Centricity Business Scheduling Department & Apppointment Typ Request Form

REQUESTOR

Select Activity: (Blank)AddEditRemove Service Request (SR) #:

Scheduling Department

Scheduling Department Name: Mnemonic: Number:

Default Scheduling Location (SD 331): Department Telephone Number (backline):

Department Grouping: RequiredFamily MedicineGen Internal MedicineGen SurgerySt LukesGeriatric MedicineHeadache CenterPhysical MedicineOBGYNWellnessPediatricsPSYCHMOB Wash Twp

Override number of days to extend master? No Number of days to extend masters? 365 Days

Corresponding Billing Area(s) (BD 202): Corresponding Billing Location(s) (BD 100):
Leave blank if multiple locations

Corresponding Billing Division: (Required)Gen Internal MedicineCenter for Children's SupportDevelopmental DisabilitiesGeriatric MedicineFamily MedicineGen SurgeryUniversity Headache CenterOBGYNWellnessPediatricsPhysical MedicinePsychSurgery (BD 102)

Address: City, State Zip:

Signature: Date:

ADD/EDIT A SCHEDULING PROVIDER FORM FOR EACH PROVIDER WITHIN THIS DEPARTMENT

Appt Types

Scheduling Department:

Copy from another scheduling dept?: NoYes Scheduling Department Name: (Blank)All Family MedicineAll Internal MedicineAll Center for AgingAll SurgeryAll WellnessPsychiatryAll OB/GynHeadache CenterPediatricsOther Copy All? YN

- NEW APPT TYPES TO BE CREATED -

One / Two / Three / Four / Five / Six / Seven
Appt Type Name:
Mnemonic:
Non-Clinic Type: / NoYes / NoYes / NoYes / NoYes / NoYes / NoYes / NoYes
Duration:
Appt. Category: / (Blank)ConsultationCounselingCrisis ContractDDD ContractDiagnostic TestingEmergencyEstablished Pt VisitInjectionsITN ContactMedication CheckNew Pt VisitNurse VisitOtherPhsyical TherapyPhysicalsPost Op VisitProcedurePsycotherapyAutism / (Blank)ConsultationCounselingCrisis ContractDDD ContractDiagnostic TestingEmergencyEstablished Pt VisitInjectionsITN ContactMedication CheckNew Pt VisitNurse VisitOtherPhsyical TherapyPhysicalsPost Op VisitProcedurePsycotherapyAutism / (Blank)ConsultationCounselingCrisis ContractDDD ContractDiagnostic TestingEmergencyEstablished Pt VisitInjectionsITN ContactMedication CheckNew Pt VisitNurse VisitOtherPhsyical TherapyPhysicalsPost Op VisitProcedurePsycotherapyAutism / (Blank)ConsultationCounselingCrisis ContractDDD ContractDiagnostic TestingEmergencyEstablished Pt VisitInjectionsITN ContactMedication CheckNew Pt VisitNurse VisitOtherPhsyical TherapyPhysicalsPost Op VisitProcedurePsycotherapyAutism / (Blank)ConsultationCounselingCrisis ContractDDD ContractDiagnostic TestingEmergencyEstablished Pt VisitInjectionsITN ContactMedication CheckNew Pt VisitNurse VisitOtherPhsyical TherapyPhysicalsPost Op VisitProcedurePsycotherapyAutism / (Blank)ConsultationCounselingCrisis ContractDDD ContractDiagnostic TestingEmergencyEstablished Pt VisitInjectionsITN ContactMedication CheckNew Pt VisitNurse VisitOtherPhsyical TherapyPhysicalsPost Op VisitProcedurePsycotherapyAutism / (Blank)ConsultationCounselingCrisis ContractDDD ContractDiagnostic TestingEmergencyEstablished Pt VisitInjectionsITN ContactMedication CheckNew Pt VisitNurse VisitOtherPhsyical TherapyPhysicalsPost Op VisitProcedurePsycotherapyAutism
# of Encounters: / 123 / 123 / 123 / 123 / 123 / 123 / 123
No Charge Visit: / NoYes / NoYes / NoYes / NoYes / NoYes / NoYes / NoYes
Exclude from Televox*: / NoYes / NoYes / NoYes / NoYes / NoYes / NoYes / NoYes

If appointment type is to be excluded from Televox, the mnemonic must begin with an “X”

Signature: Date:

Comments:

Reminder: If this is a new Scheduling Department, it will require an encounter form

IRT Dept Use Only: Add Encounter Form to Custom Report

Number:______Mnemonic:______Date Completed:______

Revised: 08/01/14