Dr. Debbie Kidd
Fax Server 
 04-02-2016 9:51:00 AM PAGE 5/010 Fax Server 
 Westside Health
 Date: 04-02-2016 
 Dr Kyle Ray, MD 
 94347 Jamie Ports Apt. 105
Bowersport, NM 23518
 Beneficiary Name: Dr. Debbie Kidd 
 birth date: 13-09-2001
 Beneficiary Phone Number: 396-940-8836 
 Sponsor Name: Jaime Hopkins 
 Sponsor SSN: xxx-xx-1802 
 Plan Type: Prime Eligible 
 Reference Number: 20699109198 
 Requesting Provider: Dr Kyle Ray, MD 
 Requesting Provider NPI: 1347568659 
 Dear Dr Kyle Ray, MD: 
 Westside Health is the Managed Care Support Contractor (MCSC) for the 
 Department of Defense's health care program, Westside Health, in your region. We thank you for your 
 continued service to our Westside Health beneficiaries. 
 We received your request for service(s) for the above Westside Health beneficiary. 
 Reason for Request: Outpatient Authorization Request 
 Servicing Provider Name: Dr Kyle Ray, MD 
 Specialty Type: Urology 
 Servicing Provider Address: 94347 Jamie Ports Apt. 105
Bowersport, NM 23518 
 Servicing Provider Phone: 354-780-2103 
 Service Type 
 Frequency 
 Surgical Care 
 57288* - 57288 16-03-2015 - 12/14/2010 1 Visit or Unit(s) 
 Dr. Debbie Kidd-KPJayaraman-00005
