Transcription of PRE-AUTHORIZATION/REFERRAL …
{{id}} {{{paragraph}}}
Example: air traffic controller
PRE-AUTHORIZATION/REFERRAL …
PRE-AUTHORIZATION/REFERRAL authorization request form INPATIENT/ACUTE ___ OBSERVATION ___ REHAB ___ LTAC ___ SNF ___ ADMISSION DATE: _____ OFFICE: OUTPATIENT: HOME HEALTH: DME: INPATIENT: SCHEDULED DATE OF SERVICE REQUESTED: _____ Patient Name (full name) _____ Member ID# _____ Date of Birth _____ PCP Name _____ PCP Phone # _____ Date Submitted_____ Requested Service(s) *Please list all CPT codes requested, please, no code code/# of units: _____ Procedure description: _____ CPT/Procedure code/# of units: _____ Procedure description: _____ CPT/Procedure code/# of units: _____ Procedure description: _____ Diagnosis ICD code(s): _____ Diagnosis description: _____ ICD code(s): _____ Diagnosis description: _____ ICD code(s): _____ Diagnosis description: _____ Requested Specialist/Provider Specialist/Provider Name Referring to: _____ Specialist/ Provider Fax #: _____ Specialist/ Provider Phone #: _____ Specialist/ Provider Tax ID#: _____ S
pre-authorization/referral authorization request form inpatient/acute ___ observation ___ rehab ___ ltac ___ snf ___ admission date: _____ office: ⃞ outpatient: ⃞ home health: ⃞ dme: ⃞ inpatient: ⃞ scheduled date of service requested: _____
Loading..
Tags:
Information
Domain:
Source:
Link to this page:
Please notify us if you found a problem with this document: