Donna Davis
Fax Server 
 20/23/05 9:51:00 AM PAGE 9/010 Fax Server 
 General Medical Center
 Date: 20/23/05 
 Dr Brian Reid, MD 
 4827 Pierce River
North Amanda, OR 26214
 Beneficiary Name: Donna Davis 
 dob: 24/03/05
 Beneficiary Phone Number: 576-859-7058 
 Sponsor Name: Beth Davis 
 Sponsor SSN: xxx-xx-1512 
 Plan Type: Prime Eligible 
 Reference Number: 92060510067 
 Requesting Provider: Dr Brian Reid, MD 
 Requesting Provider NPI: 1343192490 
 Dear Dr Brian Reid, MD: 
 General Medical Center is the Managed Care Support Contractor (MCSC) for the 
 Department of Defense's health care program, General Medical Center, in your region. We thank you for your 
 continued service to our General Medical Center beneficiaries. 
 We received your request for service(s) for the above General Medical Center beneficiary. 
 Reason for Request: Outpatient Authorization Request 
 Servicing Provider Name: Dr Brian Reid, MD 
 Specialty Type: Urology 
 Servicing Provider Address: 4827 Pierce River
North Amanda, OR 26214 
 Servicing Provider Phone: 357-436-7268 
 Service Type 
 Frequency 
 Surgical Care 
 57288* - 57288 10/19/04 - 12/14/2010 1 Visit or Unit(s) 
 Donna Davis-KPJayaraman-00009
