Zachary Carrillo
Fax Server 
 27 Sep 2018 9:51:00 AM PAGE 2/010 Fax Server 
 Lakeside Health
 Date: 27 Sep 2018 
 Dr Scott Thomas, MD 
 38840 Frey Row
South Allisonchester, TN 03494
 Beneficiary Name: Zachary Carrillo 
 date of birth: 09 Mar 1995
 Beneficiary Phone Number: 911-794-2830 
 Sponsor Name: Shelly Mathews 
 Sponsor SSN: xxx-xx-1212 
 Plan Type: Prime Eligible 
 Reference Number: 77895131128 
 Requesting Provider: Dr Scott Thomas, MD 
 Requesting Provider NPI: 1342721112 
 Dear Dr Scott Thomas, MD: 
 Lakeside Health is the Managed Care Support Contractor (MCSC) for the 
 Department of Defense's health care program, Lakeside Health, in your region. We thank you for your 
 continued service to our Lakeside Health beneficiaries. 
 We received your request for service(s) for the above Lakeside Health beneficiary. 
 Reason for Request: Outpatient Authorization Request 
 Servicing Provider Name: Dr Scott Thomas, MD 
 Specialty Type: Urology 
 Servicing Provider Address: 38840 Frey Row
South Allisonchester, TN 03494 
 Servicing Provider Phone: 429-641-1973 
 Service Type 
 Frequency 
 Surgical Care 
 57288* - 57288 13 Apr 2017 - 12/14/2010 1 Visit or Unit(s) 
 Zachary Carrillo-KPJayaraman-00002
