WJMC - West Jefferson Medical Center

WJMC - West Jefferson Medical Center


Central Scheduling Reservation

Patient Access Department

Phone: 349-6300

1-800-481-0645

7am-5pm, Monday-Friday
  
Please FAX orders to 349-6024


Identification
 
Last Name:   First Name:  
Middle Init:
Gender:  
Date of Birth:
SSN:
Mailing Address:  
City:     State:  
Zip Code:  
Home Phone:
Work Phone:
Cellular Phone:
 
 
Appointment Information
 
Department and Procedure 1:  
ICD-9 Code:  
Department and Procedure 2:
ICD-9 Code:
Department and Procedure 3:
ICD-9 Code:
 
Additional Procedures and/or Diagnosis Codes:
 
Ordering Physician's Name:  
 
 
Insurance Information, Plan 1
 
Carrier Name/Plan:  
Carrier Phone #:
Group Name:  
Group #:  
Policy #:  
Subscriber Name:  
Subscriber SS#:
Authorization Number:
 
 
Insurance Information, Plan 2 (if exists)
 
Carrier Name/Plan:
Carrier Phone #:
Group Name:
Group #:
Policy #:
Subscriber Name:
Subscriber SS#:
Authorization Number:
 
 
Medical Information

 (Please include any information pertinent to scheduling procedure)
 
Allergies:
Medications:
Special Instructions and/or Needs:
 
 
Requestor Information
 
Preferred Appt Dates and Time:  
Date of Request:
Requestor's Name:  
Requestor's Phone:
Requestor's Email and/or
Fax Number:
 
 




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