Katelyn Carlson
Fax Server 
 22-04-2020 9:51:00 AM PAGE 8/010 Fax Server 
 Meadowbrook Medical
 Date: 22-04-2020 
 Dr Brandon Holland, MD 
 67279 Taylor Fall
Barbaraton, ID 14109
 Beneficiary Name: Katelyn Carlson 
 DOB: 23-06-1988
 Beneficiary Phone Number: 429-115-2672 
 Sponsor Name: John Arnold 
 Sponsor SSN: xxx-xx-1272 
 Plan Type: Prime Eligible 
 Reference Number: 11325417549 
 Requesting Provider: Dr Brandon Holland, MD 
 Requesting Provider NPI: 1342053676 
 Dear Dr Brandon Holland, MD: 
 Meadowbrook Medical is the Managed Care Support Contractor (MCSC) for the 
 Department of Defense's health care program, Meadowbrook Medical, in your region. We thank you for your 
 continued service to our Meadowbrook Medical beneficiaries. 
 We received your request for service(s) for the above Meadowbrook Medical beneficiary. 
 Reason for Request: Outpatient Authorization Request 
 Servicing Provider Name: Dr Brandon Holland, MD 
 Specialty Type: Urology 
 Servicing Provider Address: 67279 Taylor Fall
Barbaraton, ID 14109 
 Servicing Provider Phone: 824-885-4211 
 Service Type 
 Frequency 
 Surgical Care 
 57288* - 57288 10-09-2015 - 12/14/2010 1 Visit or Unit(s) 
 Katelyn Carlson-KPJayaraman-00008
