Transcription of Comprehensive Musculoskeletal Management - eviCore
1 First Name:Middle I nitial:Last Name:DOB (mm/dd/yyyy):Gender:MaleFemaleStreet A ddress:Apt #:City:State:Zip:Cell P hone:Primary Con tact:HomeCellHealth Plan:Member ID:Group I D:First Name:Last Name:Primary S pecialty:TIN:NPI:Physician P hone:Physician Fax :Address:Suite #:City:State:Zip:Office Co ntact:Ext:Contact E mail:First Name:Last Name:Group/Site Name:Primary S pecialty:TIN:NPI:Site Phone:Site Fax:Address:Suite #:City:State:Zip:Diagnosis, i f k nown o r r ule o ut:ICD-10 Cod es:Date of l ast v isit:Page 1 of2 Authorization Fax FormPatient/MemberHome P hone:Ordering ProviderFacility/SiteProcedureList a llapplicableCPT c odesand m odifiers:CONFIDENTIALITY NOTICE: This fax transmission, and any documents attached to it may contain confidential or privileged information subject to privacyregulations such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
2 This information is intended only for the use of the recipient(s) named above. If you are not the intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified that anydisclosure, copying, distribution or use of any of the information contained in or attached to this transmission is STRICTLY PROHIBITED. If you havereceived this transmission in error, please immediately notify eviCore healthcare and destroy the original transmission and its attachments without savingthem in any NON-URGENT requests, please fax this completed document along with medical records, imaging, tests, there are any inconsistencies with the medical office records, please elaborate in the comment section. Failure to provide all relevant information may delay the request.
3 Ationzauthori an submit to site the on located portal provider the into log also may You section. Forms Fax and Guidelines the under on found be can numbers fax and URGENT (same day) REQUESTS MUST BE SUBMITTED BY healthcare | | 400 Buckwalter Place Blvd Bluffton, SC 29910 | 1. What i s th e requested s ite of s ervice?InpatientOfficeOutpatientHomeObse rvation2. What i s th e a nticipated da te of s ervice?Page 2 of 2 Clinical Information Medical do cumentation, including an exam narrative, office no tes, r esults of diagnostic tests, and any equivalent no tes mu st b e s ubmitted w ith t his form. A dditional information/comments: eviCore healthcare | | 400 Buckwalter Place Blvd Bluffton, SC 29910 |
