[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-281530-105":53,"doc-detail-281530-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","surgical-clearance-medical-provider-letter-and-outpatient-suitability-checklist","Surgical Clearance - Medical Provider Letter and Outpatient Suitability Checklist","","Surgical Clearance letter template requesting a medical provider’s authorization for an identified patient prior to surgery, including instructions to complete any required testing before the procedure date and to return the signed document with comments and results. Includes a structured outpatient suitability checklist covering general health, metabolic and hematologic markers, cardiopulmonary status, and social factors. Also provides space for additional notes and a provider clearance determination selection between outpatient suitability and required observation or inpatient status.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":41,"@type":70,"position":76},"https://docshare.wps.com/template/letters/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/surgical-clearance-medical-provider-letter-and-outpatient-suitability-checklist/281530/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/surgical-clearance-medical-provider-letter-and-outpatient-suitability-checklist/281530.png","ImageObject",442,249,{"name":88,"@type":89},"Dozel","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-22","2026-09-16",true,{"@type":98,"interactionType":99,"userInteractionCount":8},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What does the Surgical Clearance request require from the medical provider?","Question",{"text":108,"@type":109},"The letter requests medical clearance for the patient before surgery and asks the provider to complete any necessary testing prior to the surgery date, then return the signed form with test results or comments.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What items are included in the outpatient suitability checklist?",{"text":113,"@type":109},"The checklist covers general health, metabolic and hematologic criteria, cardiopulmonary status, and social factors such as home support, caregiver availability, and transportation arrangements.",{"name":115,"@type":106,"acceptedAnswer":116},"How does the provider indicate the final clearance decision?",{"text":117,"@type":109},"The provider must select one option under clearance determination: medically appropriate for outpatient joint replacement, or requiring observation/inpatient status due to medical factors, then sign and date the form.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},281530,1790006543,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":8,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},962085662650,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","Surgical Clearance  \nDate:  \nPatient: DOB:  \nSurgery:  \nDear Dr. Medical Provider,  \nI am requesting medical clearance for the above patient. We have asked the patient to schedule an appointment with you. If you feel the patient requires any testing, this would need to be completed prior to the surgery date with appropriates document clearing the patient for surgery. Please fax this letter with any comments or test results to the number below. Please feel free to contact us with any questions or concerns you may have regarding this patient and the upcoming surgery.  \no This patient has been cleared for surgery:  \no Patient is cleared for surgery and medically appropriate for outpatient status  \no Patient is cleared for surgery but requires overnight observation or inpatient status due to medical factors.  \no This patient has NOT been cleared for surgery.  \nComments:    \nSignature:   Date:    \nThank you in advance,  \nJ. Trevor Stefanski, MD  \nPlease fax finished form to: Modern Orthopedics at (513) 525-1231  \n4625 Red Bank Rd \\#101 Cincinnati, OH 45227 • (513) 525-1234  \nSurgical Clearance  \nPatient Name:   DOB:   Surgery Date (if known):    \nEvaluating Provider:    \nPractice Name:    \nPhone:   Fax:    \nI. OUTPATIENT SUITABILITY CHECKLIST(Check all that apply)  \nGeneral Health: Metabolic & Hematologic:  \no ASA I-II o HbA1c ≤ 7.5-8.0%  \no BMI ≤40 o Hgb ≥11 (female) / ≥12 (male)  \no Ambulatory without extensive assistance o eGFR >45  \no Cognitively intact o No active infection  \no Reliable home support for 24-48 hours o Anticoagulation manageable for surgery  \nCardiopulmonary Status: Social Factors:  \no No recent cardiac event (\u003C6 months) o Caregiver available for 24 hours  \no No decompensated heart failure o Safe home environment  \no No uncontrolled arrhythmia o Transportation arranged  \no OSA controlled (brings CPAP if applicable)  \nII. ADDITIONAL NOTES:  \nIII. CLEARANCE DETERMINATION (Provider must select one)  \no Medically appropriate for outpatient joint replacement  \no Requires observation/inpatient due to medical factors  \nProvider Signature:   Date:    \nPlease fax finished form to: Modern Orthopedics at (513) 525-1231  \n4625 Red Bank Rd \\#101 Cincinnati, OH 45227 • (513) 525-1234","cbCaikqGAm9awrHW","https://ap.wps.com/l/cbCaikqGAm9awrHW","pdf",188837,"English","# Surgical Clearance Request\n## Patient and Surgery Details\n## Outpatient Suitability Checklist\n## Additional Notes\n## Clearance Determination","[{\"question\":\"What does the Surgical Clearance request require from the medical provider?\",\"answer\":\"The letter requests medical clearance for the patient before surgery and asks the provider to complete any necessary testing prior to the surgery date, then return the signed form with test results or comments.\"},{\"question\":\"What items are included in the outpatient suitability checklist?\",\"answer\":\"The checklist covers general health, metabolic and hematologic criteria, cardiopulmonary status, and social factors such as home support, caregiver availability, and transportation arrangements.\"},{\"question\":\"How does the provider indicate the final clearance decision?\",\"answer\":\"The provider must select one option under clearance determination: medically appropriate for outpatient joint replacement, or requiring observation/inpatient status due to medical factors, then sign and date the form.\"}]","Surgical Clearance - Medical Provider Letter and Outpatient Suitability Checklist | PDF",1789566612]