ࡱ> c v]bjbjZZ .8b\8b\J T VV8B:Z@@@@: L!(AAAAAAA$DzGAQ@!@@!@!AVV@@DB^%^%^%@!RV@V8@A^%@!A^%^%E89@F!R8AZB0B8I!I(9I9@!@!^%@!@!@!@!@!AA#@!@!@!B@!@!@!@!I@!@!@!@!@!@!@!@!@! > :  Site  FORMTEXT      Date Surgical Contracts Desk Received (yyyy-Mon-dd)  FORMTEXT       (AHS Use Only) Date Submitted (yyyy-Mon-dd)  FORMTEXT      Surgeon s Name (Last, First)  FORMTEXT      Surgeon s Phone  FORMTEXT      1Patient InformationLast Name  FORMTEXT      First Name  FORMTEXT      Middle Name  FORMTEXT      Age  FORMTEXT    Date of Birth (yyyy-Mon-dd)  FORMTEXT       FORMCHECKBOX  Female  FORMCHECKBOX  MalePersonal Health Number  FORMTEXT      Cancer  FORMCHECKBOX  Yes  FORMCHECKBOX  NoCancer Suspected  FORMCHECKBOX  Yes  FORMCHECKBOX  NoA-CATS Diagnosis Code  FORMTEXT      SignatureDesignation  FORMTEXT      Date (yyyy-Mon-dd)  FORMTEXT      2Booking Information Decision Date for Surgery (yyyy-Mon-dd)  FORMTEXT      Ready to Treat Date (yyyy-Mon-dd)  FORMTEXT      Admit Category  FORMCHECKBOX  Elective  FORMCHECKBOX  Urgent 3 day  FORMCHECKBOX  Urgent 7 day  FORMCHECKBOX  Urgent 14 day  FORMCHECKBOX  Urgent 28 day  FORMCHECKBOX  Urgent 42 dayProcedure 1 Description +/- Code  FORMTEXT       FORMCHECKBOX  Right  FORMCHECKBOX  Left  FORMCHECKBOX  BilateralSurgeon 1  FORMTEXT      Procedure 2 Description +/- Code  FORMTEXT       FORMCHECKBOX  Right  FORMCHECKBOX  Left  FORMCHECKBOX  BilateralSurgeon 2  FORMTEXT      Procedure 3 Description +/- Code  FORMTEXT       FORMCHECKBOX  Right  FORM  $&(246@dͿfTC2 hY#ch JCJOJQJ^JaJ hY#chqCJOJQJ^JaJ#hY#chq5CJOJQJ^JaJ4jhY#ch6CJOJQJU^JaJmHnHu/jhY#chLCJOJQJU^JaJ hY#ch6CJOJQJ^JaJ)jhY#ch6CJOJQJU^JaJhY#cCJOJQJ^JaJ hY#ch CJOJQJ^JaJ hY#chfICJOJQJ^JaJ hY#chbZCJOJQJ^JaJ 68 ` Wkd$$Ifl40*r 6 f0P+4 lae4f4yt3($f& #$/Ifb$gd/ @ P]Pgd^ dfnpͼsY=()hY#ch6B*CJOJQJ^JaJph7jhY#ch=5CJOJQJU^JaJmHnHu2jjhY#chi85CJOJQJU^JaJ#hY#ch=5CJOJQJ^JaJ,jhY#ch=5CJOJQJU^JaJ#hY#chY#c6CJOJQJ^JaJhY#cCJOJQJ^JaJ hY#chnCJOJQJ^JaJ hY#chl/CJOJQJ^JaJ hY#ch3TCJOJQJ^JaJ hY#ch^-CJOJQJ^JaJ  6 8 : N P R 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"6ugP>#hY#chY#c5CJOJQJ^JaJ,jhY#chY#c5CJOJQJU^JaJhyFCJOJQJ^JaJ/j\hY#chY#cCJOJQJU^JaJ/jhY#chY#cCJOJQJU^JaJh>CJOJQJ^JaJh/CJOJQJ^JaJ hY#chY#cCJOJQJ^JaJ)jhY#chY#cCJOJQJU^JaJ/jhY#chY#cCJOJQJU^JaJ Hxwww\www l @@($f& #$/Ifb$gd/($f& #$/Ifb$gd/qkd$$Ifl4$*P+ 6 f0P+4 lae4f4yt368:DFHJfhjlxzϳϢϐvϐϐ\Nϐ42jhY#chY#c5CJOJQJU^JaJh/CJOJQJ^JaJ2j0hY#chY#c5CJOJQJU^JaJ2jhY#chY#c5CJOJQJU^JaJ#hY#chY#c5CJOJQJ^JaJ hY#chY#cCJOJQJ^JaJ7jhY#chY#c5CJOJQJU^JaJmHnHu,jhY#chY#c5CJOJQJU^JaJ2j^hY#chY#c5CJOJQJU^JaJ   \^`tvxƱƙ~pV:7jhY#chY#c5CJOJQJU^JaJmHnHu2j&hY#chY#c5CJOJQJU^JaJhyFCJOJQJ^JaJ4jhY#chY#cCJOJQJU^JaJmHnHu/jhY#chY#cCJOJQJU^JaJ)jhY#chY#cCJOJQJU^JaJ hY#chY#cCJOJQJ^JaJ#hY#chY#c5CJOJQJ^JaJ,jhY#chY#c5CJOJQJU^JaJ^gQQQ6Q l @@($f& #$/Ifb$gd/($f& #$/Ifb$gd/kdj$$Ifl4F*P 6 f0P+    4 lae4f4yt>02FHJϽϽτϽjϽU=U/jhY#chY#cCJOJQJU^JaJ)jhY#chY#cCJOJQJU^JaJ2j`hY#chY#c5CJOJQJU^JaJhyFCJOJQJ^JaJ2jhY#chY#c5CJOJQJU^JaJ hY#chY#cCJOJQJ^JaJ#hY#chY#c5CJOJQJ^JaJ,jhY#chY#c5CJOJQJU^JaJ2jhY#chY#c5CJOJQJU^JaJ0XZQkd2$$Ifl42F*P 6 f0P+    4 lae4f4yt>($f& #$/Ifb$gd/JTV^пnR82jXhY#chY#c5CJOJQJU^JaJ7jhY#chY#c5CJOJQJU^JaJmHnHu2jhY#chY#c5CJOJQJU^JaJ#hY#chY#c5CJOJQJ^JaJ,jhY#chY#c5CJOJQJU^JaJhyFCJOJQJ^JaJ hY#chY#cCJOJQJ^JaJ)jhY#chY#cCJOJQJU^JaJ4jhY#chY#cCJOJQJU^JaJmHnHuCHECKBOX  Left  FORMCHECKBOX  BilateralSurgeon 3  FORMTEXT      SignatureDesignation  FORMTEXT      Date (yyyy-Mon-dd)3Surgical Contracts Desk Use Only BURN  FORMTEXT      Initials  Instructions: The Surgical Contracts (formerly NHSF) Booking/Waitlist Request must be completed for all insured surgery performed on Alberta residents in a private facility, excluding WCB claimants. This form is available on the Alberta Health Services external website at  HYPERLINK "http://www.albertahealthservices.ca/4896.asp" http://www.albertahealthservices.ca/4896.asp Completed Surgical Contracts Booking/Waitlist Requests are to be submitted daily to Surgical Contracts Desk. Form submission: (1) Secure E-mail  HYPERLINK "http://mail.calgaryhealthregion.ca/owa/redir.aspx?C=65e76800fc304f73ab460479232a0a0d&URL=mailto%3aNHSFCaseManagement%40albertahealthservices.ca" NHSFCaseManagement@albertahealthservices.ca (Approved Sites), (2) or Fax (403) 944-4010. Questions/Concerns: Contact the Surgical Contracts Office FMC - ST, 9th Floor, Room 904, 3031 Hospital Drive NW Calgary, Alberta T2N 2T8, (403) 944-4410 or email  HYPERLINK "http://mail.calgaryhealthregion.ca/owa/redir.aspx?C=65e76800fc304f73ab460479232a0a0d&URL=mailto%3aNHSFCaseManagement%40albertahealthservices.ca" NHSFCaseManagement@albertahealthservices.ca      Surgical Contracts Booking/Waitlist Request 21166 (2018-03) Affix Patient label RRRR R"R$R@RBRDRFRnRpRRRRRRRѺ끺lTl9l4jhY#chY#cCJOJQJU^JaJmHnHu/jhY#chY#cCJOJQJU^JaJ)jhY#chY#cCJOJQJU^JaJ2j(hY#chY#c5CJOJQJU^JaJ hY#chY#cCJOJQJ^JaJhyFCJOJQJ^JaJ,jhY#chY#c5CJOJQJU^JaJ2jhY#chY#c5CJOJQJU^JaJ#hY#chY#c5CJOJQJ^JaJU"RZRnRRRR6kd$$Ifl4F*P 6 f0P+    4 lae4f4yt>($f& #$/Ifb$gd/ l @@($f& #$/Ifb$gd/RRRRRRRRRRRRSSS^ShSjSʸʂpYL;-hY#cCJOJQJ^JaJ hY#chY#cCJOJQJ^JaJhY#chY#cCJ^JaJ,hY#chY#c5B*CJOJQJ^JaJph#hY#ch/6CJOJQJ^JaJ7jhY#ch/5CJOJQJU^JaJmHnHu2jhY#ch/5CJOJQJU^JaJ#hY#ch/5CJOJQJ^JaJ,jhY#ch/5CJOJQJU^JaJ hY#ch/CJOJQJ^JaJh/CJOJQJ^JaJRRRSSSQ=$f& #$/Ifb$gd/kd $$Ifl4F*<  6 f0P+    4 lae4f4yt3($f& #$/Ifb$gd/S^S`SjSSSSL6666($f& #$/Ifb$gd/kd$$Ifl40 *v)  6 f%0P+4 lae4f4p%yt3$f& #$/Ifb$gd/jSlSSSSSSSSSSSSSS׽q`I7& hyFhWCJOJQJ^JaJ#hyFhW>*CJOJQJ^JaJ,hY#ch7U>*B*CJOJQJ^JaJphGGG hY#ch/CJOJQJ^JaJh/CJOJQJ^JaJ hY#chY#cCJOJQJ^JaJ hY#chyFCJOJQJ^JaJ7jhY#chyF5CJOJQJU^JaJmHnHu2jhY#chyF5CJOJQJU^JaJ#hY#chyF5CJOJQJ^JaJ,jhY#chyF5CJOJQJU^JaJSSSS8UV~Wzqq_I_ & F?d7$8$H$]?gdW & Fd7$8$H$gdW 7$8$H$gdWkd$$Ifl4e0*b 6 f0P+4 lae4f4ytyFSSSSST"T4TTTTUUUBVDVFVVVVVVV6Wضأ~h~Oh@hضhY#ch|0JOJQJ^J0jhY#ch6xB*OJQJU^Jph*jhY#ch|B*OJQJU^Jph!hY#ch|B*OJQJ^Jph'hY#chW6B*OJQJ]^Jph$hY#chWB*OJQJ]^Jph!hY#chYB*OJQJ^Jph!hY#chocB*OJQJ^Jph!hY#chWB*OJQJ^Jph,hY#chW>*B*CJOJQJ^JaJphnnn6WBWJWpWxW~WWWWYYXYZYYYY˺ܩwwcM8(hY#chCJOJQJ^JaJmH sH *jhY#chB*OJQJU^Jph'hY#ch0JOJQJ\^JmH sH 5jhY#chB*OJQJU\^JmH phsH ,hY#chB*OJQJ\^JmH phsH !hY#chB*OJQJ^Jph!hY#ch,B*OJQJ^Jph!hY#chB*OJQJ^Jph!hY#chWB*OJQJ^Jph$hY#chW5B*OJQJ^Jph~WY\\\\\\\\\\\\\\\\]]8]:]<]>]@]B] & F7$8$H$gd  & Fd7$8$H$gdYYZ(Z,Z^ZjZZZZZ8\:\\\DzmmV<2jhY#chB*CJOJQJU^JaJph,hY#ch0JCJOJQJ^JaJmH sH 1jhY#chCJOJQJU^JaJmH sH (hY#chCJOJQJ^JaJmH sH -hY#chB*CJOJPJQJ^JaJph)hY#chB*CJOJQJ^JaJph,hY#ch5B*CJOJQJ^JaJph hY#chocCJOJQJ^JaJ hY#chCJOJQJ^JaJ\\\\\\\\\\\\\\\]]]8]:]<]j]l]n]p]r]t]v]ںseTs!h hyFB*OJQJ^Jphh B*OJQJ^Jph!h h B*OJQJ^Jph h|j~h|j~CJOJQJ^JaJhW#h/h 5CJOJQJ^JaJh 5CJOJQJ^JaJ#h h 5CJOJQJ^JaJjh UmHnHuh hS9%f֎L'*9ƾʽۿ7ʟ'd',ix}+;'ŵἀ/%|6烻<Zo>=1d/UA p~rZBΓK_ŕtT0N}_tW1Ob~7?~oVWhޏޘ~9ho ">K& j2 T <`}M2a%ҚN}xZKzAHŀ2nckdv<ۑ ϝ8.5b/{O=:y> _$ðx6q'~-zޣɢd4%O.sǃ5B??d//wu꫷&'p|pkr||˼껽 ^y>`8f=Ǵʐh8o&7޲ѹ󓃱7ndzbp2;޳$7Z#߬6IZh(w>m̢䖰ϲhɔ&hMz8HOd|fHLNj|Z noh2݌f@ z'z?>kQH<ޘ=XކX-bx͎ F_?N[iӭ897Zw=ݷ`Զtc"?y*w9RVMfzSFO2t% .La뵷&]͏Of0&E ]_3L%h*f+؏T*{;-o^DV>ײ*#<lj{ _UOfy: ^av&xl6Yx.0Wq](dvŇp(z/znu*jY-6f@ܬ6f"ݰn m7[P=r7OwF~9*cl g瑗tq{{3">~PFe3ݛtJyrN~k\LOѨwb7o1I>w~o*oB1"n NL <0^ojKU;'ӉԣI{= k7;`od|DX gwpO wNN4=Χɬ7ƤdTy3ͳ pq<%fi~ z\ ?"D*gKX߽~8cؒͿYKH`bJ$l+=Hwퟥg8׽i>þJpIY:G I(?R)QF^5䄖<='t~Ƚ]2ӣ7pLJp2vDV`8R GYDixI8vқCS{}ΐя-"jzT>騺M'nJӛwmOI8w;;{n=7^4^c0}-zf=f=d:GgK'}@:00axp2E&7rWS yܨ^|G+0E<] $<&廊pG`St ݘa4fjâ[|fMܬI4k9N:q :qOhI1]C~#eOV ?_X"O/H޲"hhrHo'׈E"3ΞUHRVW*O_xO۾|K˯]/g ʷ ?EλoEđ =k0}AF)PdqG{m)kdg2S9<'NGڙ:BOW*d8K$Xd~49¬n5>8ȟfL跱+ LOM%{TH1b|;c {n(DiGsI?F7d0%ۑNFMN>0H NKrVQӪr[AGj T&<[O>xOK  ,FDX:*BVgGXKcp1,p2]FLq'=3Cd"1|=y\=N{@,V⣟nBOL25"^nDF PCv>K^iʷܷ89!ϳ<,!W+`vWZ,ό^]!Dnm;b}]eO4jjwuj]ɖ\^wu,7f[C||2#s07ă|W$}7>|#cGԓ䳼{Ƽhy@'bB)$-{Aܾak2:D(R߼ݻ)t.Է{ǽ7;݃cr9YM/Z\Lu5NJ%i7Ptu a7xj}Pnt#T$WU'FA$N^t(x}znlC~o~s1ɒT 7꟤X/=-A~g6X+%,B;+]Z,M f66jCS;zlAmT*mWTajPۥNCL7 |j4)-(ZjFdI[s}_l az&֋oL);=Ā?{Z hƘޘ^Ԓ"j eRPt$Y4뻖-&$D;Lޱ7ndm׿sÝ뚄j:rF1>8]ȯL>?NS =>&="Bvu.h)[d*VlqglT ᠧ9;8}a tI`ݟLR:k.W*4YG0FVU>.NƎRyq{6>?c ` ; MƗ+)GH[(tdcTԧ{P6 Ah%.\LPbBY\> B hrhI>{3r~/)j#?(,f횜B |i~~}mƙRg#pX?"h@IAyE=<ؓ՜ .ÌgOm~x ԢCMU+(W ԭ2c |{w̓Fqu(/e:E ˀ:)4FZKr2u:]^I1!4wWE}pu@N=i.&* ׶Vp^XuΑ /:) 85)cc[|Wp e50ċ`Mcwl,d 9Gğȳ0i9)(S.ޟI3_v Z~Mgg{q`EW."|;eHA8b)ٌζx$:E tQ8w<[||UaWke"sg4׷C ^xң9k"<`$eZYƫ +1#1? 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