Just Fax It - Seton Medical Center Harker Heights 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name and Social Security number in the designated fields. Ensure accuracy for proper identification.
3. Fill in the patient's address, including city, state, and zip code. This information is crucial for communication and scheduling.
4. Provide both home and business/mobile phone numbers to facilitate contact regarding the exam.
5. Indicate the patient's sex and age, along with their date of birth to ensure correct patient records.
6. List primary and secondary insurance details accurately. Remember to fax a copy of the insurance card (front & back) along with this form.
7. Specify if pre-certification is needed by selecting 'Yes' or 'No'.
8. Detail the procedure/exam requested, including any necessary CPT codes. Be thorough to avoid delays.
9. Provide a clinical indication along with ICD 9/10 codes, ensuring all pertinent clinical information is included without symbols or abbreviations.
10. Finally, have the ordering physician sign, date, and time the form. Include their contact information for follow-up.

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