|||1|January 3, 2025|||1|500|||1|Devin Slick500|||1|500|||1|508 Pineview Dr
Euless TX Dear |||1|
Devin|||1|
:

After a review of your referral, Baylor Scott and White Health has sent your referral to the provider below.

You may want to contact 501|||1|
CIGNA501|||1|
to verify in-network coverage prior to your appointment. If you do not already have an appointment, please call to make an appointment
with 501|||1|***501|||1|501|||1|817-421-If you have any questions regarding the referral, please contact your referring provider 501|||1|
817-912-8800
501|||1|"

Sincerely,
Baylor Scott & White Health

Information for Referral #: 
501|||1|"41130016
501|||1|501|||1|Diagnoses:
729.5 (ICD-9-CM) - M79.671 (ICD-10-CM) - Acute pain of right foot501|||1|501|||1|Procedures:
REF62 (Custom) - AMB REFERRAL TO ORTHOPEDIC SURGERY501|||1|Authorization #: 501|||1|501|||1|Referring Provider Information
501|||1|Kimberly Diann Benko501|||1|501|||1|925 E SOUTHLAKE BLVD Suite 100
Southlake,  TX -912-Referring To Provider Information
501|||1|Jordan James Ernst501|||1|501|||1|***501|||1|501|||1|501|||1|501|||1|815 Ira E Woods Ave
Suite 100
GRAPEVINE TX -421-Referral Start Date:
501|||1|12/20/2024
501|||1|Referral End Date:
501|||1|03/21/2026
501|||1|