{Date} Elective Surgery Notification {Insurer's name} {Address} {City, state, ZIP} {Phone number} {Fax number} Re: Worker name: Claim number: Date of birth: Date of injury: Provider222s notice of proposed elective surgery Practice name: Ordering physician: Address: Phone number: Fax number: We have scheduled the following elective surgery for the above - named worker: Procedure: CPT codes: Diagnosis/ICD - 10: Outpatient: Inpatient: Anticipated length of stay: Date scheduled: Hospital/facility: Provider: Attach supporting documentation ( e.g., chart notes ) . 5425 440 - 5 425 ( 4/19 /DCBS/WCD/WEB) American LegalNet, Inc. www.FormsWorkFlow.com