Alexandra Kemp
Fax Server 
 06 Jun 2021 9:51:00 AM PAGE 7/010 Fax Server 
 Oak Grove Hospital
 Date: 06 Jun 2021 
 Dr Rachel Dominguez, MD 
 1884 Bolton Cliff Suite 446
West Michael, MN 34751
 Beneficiary Name: Alexandra Kemp 
 birth date: 30 Mar 1990
 Beneficiary Phone Number: 715-968-2775 
 Sponsor Name: Kevin Gay 
 Sponsor SSN: xxx-xx-1892 
 Plan Type: Prime Eligible 
 Reference Number: 19530069092 
 Requesting Provider: Dr Rachel Dominguez, MD 
 Requesting Provider NPI: 1341104067 
 Dear Dr Rachel Dominguez, MD: 
 Oak Grove Hospital is the Managed Care Support Contractor (MCSC) for the 
 Department of Defense's health care program, Oak Grove Hospital, in your region. We thank you for your 
 continued service to our Oak Grove Hospital beneficiaries. 
 We received your request for service(s) for the above Oak Grove Hospital beneficiary. 
 Reason for Request: Outpatient Authorization Request 
 Servicing Provider Name: Dr Rachel Dominguez, MD 
 Specialty Type: Urology 
 Servicing Provider Address: 1884 Bolton Cliff Suite 446
West Michael, MN 34751 
 Servicing Provider Phone: 820-965-7845 
 Service Type 
 Frequency 
 Surgical Care 
 57288* - 57288 16 Nov 2021 - 12/14/2010 1 Visit or Unit(s) 
 Alexandra Kemp-KPJayaraman-00007
