To Schedule an Upper Endoscopy and/or Colonoscopy with Worker's Comp Insurance

AUTHORIZATION LANGUAGE

If Dr. Woolf is being asked to do a procedure through worker's comp insurance,

Please provide us with authorization in the wording below to avoid delays. Authorizations submited without this specific layout and without the items below, will not be in que for scheduling. The office can schedule once all items have been submitted. Submit all items to info@grahamwoolfmd.info. Please put in the subject - "Documents for WC procedure" for fastest turnaround.

If Dr. Woolf has seen the patient as a QME or AME, we understand that he has authority to do any tests he sees necessary but this authorization is still needed. We cannot book the test at our facility without it. Thank you for your cooperation. 

1. Authorization as outlined below

2. Intake sheet

3. History & Physical Form (Our office's Pre-procedure questionnaire must be completed by the patient or a representative can assist them filling it up). and

4. The referring physician's medical report (only the one report mentioning the recommomendation of an endoscopy and/or colonoscopy. DO NOT SEND MEDICAL RECORDS!)

Please provide authorization as follows below based on what is needed. Please use this specific wording and on the insurance letterhead signed by the adjuster.

FOR AN UPPER ENDOSCOPY

1. Authorized: Dr. Woolf to perform an upper endoscopy with biopsies

2. Authorized: to be performed at Specialty Surgical Center (8670 Wilshire Blvd. Suite 300 Beverly Hills, CA 90211)

3. Authorized: Emetrius/VitalDX/PathMD Labs to run pathology on the biopsies taken during the endoscopy

4. Authorized: Anesthesia (TIVA) during the endoscopy

FOR A COLONOSCOPY

1. Authorized: Dr. Woolf to perform a colonoscopy with possible biopsies

2. Authorized: to be performed at Specialty Surgical Center (8670 Wilshire Blvd. Suite 300 Beverly Hills, CA 90211)

3. Authorized: Emetrius/VitalDX/PathMD Labs to run pathology on the biopsies taken

4. Authorized: Anethesia (TIVA) during the colonoscopy

5. Authorized: Golytely/Gavilyte Bowel Prep 

_______________________________________________________________________________________________________________

Note: Golytely/Gavilyte is the medication for the bowel preparation for the colonoscopy and it is to be filled by a pharmacy.

FOR AN UPPER ENDOSCOPY AND COLONOSCOPY

1. Authorized: Dr. Woolf to perform an upper endoscopy with biopsies

2. Authorized: Dr. Woolf to perform a colonoscopy with possible biopsies

3. Authorized: to be performed at Specialty Surgical Center (8670 Wilshire Blvd. Suite 300 Beverly Hills, CA 90211)

4. Authorized: Emetrius/VitalDX/PathMD Labs to run pathology on the biopsies taken

5. Authorized: Anethesia (TIVA) during the endoscopy and colonoscopy

6. Authorized: Golytely/Gavilyte Bowel Prep 

_______________________________________________________________________________________________________________

Note: Golytely/Gavilyte is the medication for the bowel preparation for the colonoscopy and it is to be filled by a pharmacy.

Without providing all the mentioned documents, your request will not be in que for scheduling. Please send all docs to avoid delays (Authorization as outlined above, an intake/demographic sheet, our offices pre-procedure form filled out by the applicant and the referring physician's medical report showing their recommendation for the test)