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REFERENCE NUMBER: {{ReferenceNumber}}

Admission Notification

NPI Number

Patient First Name

Required 2-50 letters and - only

Patient MI

0-1 Letter

Patient Last Name

Required 2-100 letters and - only

DOB

Required Invalid date!

Member Number

Admission status

Hospital Name

Hospital Phone

New Hospital Name

New Hospital Phone

Caller First Name

Required 2-50 letters and - only

Caller last Name

Required 2-50 letters and - only

TIN

Call back phone

Admission date

Required Invalid date!

Admission Time

Required
Admission time cannot be set in the future

Physician First Name

Required 2-50 letters and - only

Physician Last Name

Required 2-50 letters and - only

ICD10 Codes

Required 2-50 letters and - only Code: {{ $select.selected.NumberCode }}
  • {{icd9Item.NumberCode}} {{icd9Item.Description}}